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The School Nurse Rucksack Project Leader name: Jacqueline Jones Project team: Rebecca Icke, Barbara Morgan, Gwennan Williams, Caroline

Williams and Head of Year 9 Mr Gavin Hayes Email contact details: jacqueline.jones13@wales.nhs.uk Date of project: November 2014 - June 2016 Report submitted: February 2017 Summary A Framework for a School Nursing Service for Wales (2009) sets out the Welsh Government’s approach to developing a school nursing service for children and young people that is visible, safe and accessible to a high standard. The World Health Organisation’s 4 year study on health behaviours of school aged children worldwide identified consistent health compromising behaviours in 13 to 15 years olds (World Health Organisation, 2010). The School Nursing Team in Hywel Dda University Health Board is managed through the three constituent Counties – Carmarthenshire, Pembrokeshire and Ceredigion. Carmarthenshire is approximately 2,400 km2 in size making it the 3rd largest county in Wales. From information obtained from the project team’s Health Board Child and Adolescent Mental Health Service the number of referrals to their service is higher in this age group than any other. The project leader, as part of a Specialist Community Public Health Nurse degree, developed the idea of a school rucksack as a teaching aid which would incorporate items to enable the school nurse to ask young people “What is in your rucksack that is bothering you?” The aim of this project was to build on this initial work and to raise the profile of the school nurse by engaging the participation of key stakeholders including pupils. The project team used a mixed methods approach. These included meeting key stakeholders in schools, staff development sessions, presentation at a local university, promoting the project in the Domestic Abuse Forum, pupil questionnaires and focus groups, using posters as visual aids and writing a press release for the trust newsletter. Observational techniques were used and recorded during the focus group sessions with pupils. The project has seen the introduction of a referral process between school staff and the school nurse which will be audited at the end of the school year in order to plan resources and improve

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time management. The school nurse poster is a visual aid to inform pupils and visitors who their school nurse is, what they look like, when they are in school and how to contact them. The pupil questionnaires provided an insight into how pupils wish to contact their school nurse and the issues they would like to discuss further. The project has given the larger school nursing team the “School Nurse Rucksack” to pilot as a visual aid, as a vehicle to help pupils in identifying the school nurse and facilitating a discussion on health promotion subjects. Background The project leader is a qualified and practising school nurse in Carmarthenshire West Wales employed by the Hywel Dda University Health Board. During her Specialist Community Public Health Nurse degree, the project leader was invited by the deputy head of a local comprehensive school to speak to a class of year 9 pupils (age 13 and 14) during their Personal, Social and Health Education lessons in order to identify some of the issues affecting their health and emotional wellbeing. The session involved a discussion on what makes them anxious and how would they deal with it. Pupils were asked to write their answers on sticky notes which were collected and themed. The main issues were the pressure of school exams, falling out with friends, internet bullying, weight issues and arguments with parents. Positive coping mechanisms included speaking to friends, telling a teacher and exercise, whilst harmful coping mechanisms included self-harming, alcohol and smoking. A small number of pupils said that speaking to the school nurse was an option. The project leader introduced specific information about the advice and support available both from the named school nurse and the school nursing service. This information helped to demonstrate to the young people that the school nurse was up to date and knowledgeable on the real issues affecting their emotional wellbeing. Reflecting on the session, the project leader realised that making the school nurse more visible within school would help encourage young people to access the school nurse when they started struggling with issues, so that support and advice offered could be pro-active, rather than reactive. The information the project leader had gathered from the pupils and an idea the project leader was developing separately led to the concept of “The School Nurse Rucksack”. Pupils traditionally associate the school nurse with the yellow immunisation sharps boxes and the project leader wanted to replace this image with a more positive one, hence the rucksack. The navy rucksack with a School Nurse/ Nyrs Ysgol logo was designed and professionally embroidered (see Appendix 1). The school nurse would carry the rucksack with her when she was in school and be recognisable to the pupils, raising the profile of the school nursing service. Most school children carry a rucksack or bag to school. In addition it could be used as a teaching aid by containing recognisable items to provoke discussion. The items chosen for inclusion, based on the Personal, Social and Health Education session were:

• a school book to signify pressure of exams and school work • a lunch box (with the project leader’s lunch in!) to signify healthy and unhealthy lifestyle and

eating disorders • house keys to illustrate issues at home and arguments with parents • a mobile phone to promote a discussion on issues including ‘Snap chat’, ‘Instagram’ and

sending inappropriate photos • a laptop to introduce the issues of internet security and social media being used in a

negative way To lead discussion to the question: What is in your rucksack that is bothering you?

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The setting The School Nursing Team in Hywel Dda University Health Board is managed through the three constituent counties – Carmarthenshire, Pembrokeshire and Ceredigion. Carmarthenshire is approximately 2,400 km2 in size making it the 3rd largest county in Wales, however its population density (75people per km2) makes it amongst the most rural. 99% of the population are white British, and nearly 64% speak or understand Welsh. Carmarthenshire County School Nurse Team has 12 mainstream secondary schools, 2 special schools, 2 private schools and 105 primary schools in its catchment area. The school nursing team are based in satellite offices in the county and travel to their primary and comprehensive schools from their base. Within the Carmarthenshire School Nurse Team there is one team leader (who also carries a caseload) and 18 school nurses (11 with Specialist Community Public Health Nurse (SCPHN) qualification). The team includes paediatric and adult trained nurses, midwives and is supported by 2 healthcare support workers (HCSW). Each Band 6 school nurse is a named nurse for one secondary school and its feeder primary schools. The age range of the school pupils is 5 – 18yrs, with an average case load being approximately 2,000 young people. The team is divided into three geographical locations, in the most deprived areas the band 6 school nurses are supported by a band 5 staff nurse and a HCSW. The school nursing team responsibilities include school entry health screening. The school screening programmes identifies unmet needs, and promotes early intervention by the school nurse, as part of a multi-disciplinary team, to promote positive outcomes for children and young people. Health promotion sessions include hand-washing sessions, puberty and growing up talks, health promotion and sexual health education. The school nurses have a key safeguarding role and are involved in all aspects of child protection and ‘looked after’ children, regularly attending meetings, case conferences and having regular contact with identified vulnerable children/young people. Each named school nurse for a comprehensive school is also required to manage a ‘drop-in’ clinic at least once a week in school in order for pupils to access advice and support on a regular basis. What was the impetus for the project? The World Health Organisation’s 4 year study on health behaviours of school aged children worldwide, identified consistent health compromising behaviours in 13 to 15 years old (World Health Organisation, 2010). From information obtained from the Health Board, the number of referrals to the school nurse is higher in this age group than any other. In addition referrals to the Health Board’s Child and Adolescent Mental Health Service (CAMHS) from January to November 2013 recorded a significant increase in 13 and 14 year olds at 16% and 15% in relation to younger age groups. The main referrer to the CAMHS is the general practitioner (GP) at 52% and the school nurse at 12% (Child and Adolescent Mental Health Service, 2013). With specific reference to these 13-14 year olds, the evidence suggests that many of these young people will reach a crisis and access the local GP with parents before seeking help earlier from their school nurse. This suggested to the project leader that it is essential to raise the school nurse’s profile in comprehensive schools in order for children and young people to actively access the service. Current practice requires that the school nursing team is central to a range of services that promote and support the physical, social and emotional health of children and young people and contributes to a healthy school culture. A key part of the school nurse’s role is to contribute either directly or indirectly to a range of educational and health outcomes, which include positive mental health and wellbeing. Despite these recommendations, a report by the British Youth Council suggest that this is not always the case (British Youth Council, 2011). The key message from the report is that the school nursing service should be visible, accessible and confidential. This would appear to lend weight to the project leader’s own practice findings and provided the impetus for this project.

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Aim To work within one secondary school to listen to pupils and staff to help make the school nursing service more visible, accessible and relevant to young people. Objectives

• Set up an advisory group to get sign up for the work – Group made up of senior nurses, teachers and school management

• Analyse and describe the current school nursing service • Gain the views of young people as to what they would like from their school nursing service • Engage with the nursing team to identify the gaps between the service that is provided and

the service the young people think would be beneficial to them • Work with the nursing team to develop a shared vision for a revised service • Seek engagement from school teachers and staff to identify and remedy the gaps between

the environment that is provided for the service and the environment required to implement the improved service

• Work as a stakeholder group with young people, their parents, the teachers and other school nurses to plan an improved service

• Facilitate the identified changes to the service through future work • Facilitate the lead applicant and the team of school nurses to learn through their work by

sharing final findings in school nurse meetings Methods and Approaches The project team used a mixed methods approach. This included meetings with key stakeholders in school, staff development sessions, presentations at a local university, promoting the project in a domestic abuse forum, pupil questionnaires and focus groups, using posters as visual aids and writing a press release for the trust newsletter. Observational techniques were used and recorded during the focus group sessions with pupils. Table 1: Timeline of events 2nd Oct 2014 1st Stakeholder meeting in school, head of year 9 and senior management team

14th Oct 2014 The school nurse checklist completed to assess the visibility of the school nursing service in school

15th Oct 2014 Literature review revisited to address findings of school nurse checklist 21st Oct 2014 Introduction of School Nurse Poster to advertise drop in clinic (Appendix 1) 18th Nov 2014 Bilingual school nurse referral form available to all heads of year (Appendix 2) 20th Jan 2015 List of possible focus group participants received from head of year

9th Feb2015 FoNS practice development facilitator leads a shared values exercise with school nursing team (Appendix 3)

2nd June 2015 Year 9 questionnaires completed (Appendix 4)

16th June 2015 Meeting with key members of project team to discuss pupils’ comments in questionnaire and plan 1st focus group

14th Sept 2015 1st Focus group meeting 21st Jan2016 2nd Focus group meeting 25th May 2016 3rd Focus group meeting 1st Stakeholder Meeting Oct 2014 The 1st stakeholder meeting with the school senior management team was held to discuss the aims and objectives of the project fully. This was organised and led by the project leader who emailed and telephoned each member of staff. It was agreed that the project would provide an opportunity to

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raise the profile of the named school nurse in school in order for pupils to access the service in a more proactive and relevant manner. A number of ethical considerations were discussed and examined during the first stakeholder meeting around the question of children participating in focus groups and the professional accountability of registered nurses (Nursing and Midwifery Council, 2008). School based focus groups enable direct contact with the participants and additional insights can also be obtained by observing ‘non-verbal behaviours’ (Gibson, 2012). The Head of Year 9 agreed to identify pupils from year 9 and invite them to discuss participation with the project leader. Those pupils’ parents and carers would then be written to explaining the aim of the focus group and consent would be requested (Appendix 5). Confidentiality is paramount and all data would be kept on a password protected computer and all paperwork locked in the project team office situated in the main school nursing base. The senior management team gave their full support and agreed to release pupils from some of their Personal, Social and Health Education lessons with the agreement of the Head of Year 9. Barriers to introducing a highly visible school nursing service were discussed including the idea that some teachers may not view the school nurse as an equal member of the school multi-disciplinary team and release pupils from class (Taylor and Field, 2007). It was agreed that a meeting between heads of year and the named school nurse in order to discuss the role and the service in more detail would be an opportunity to overcome this. There was also a discussion about the need to use a more structured and transparent referral process. All agreed the time constraints of the school term, holidays and the impact of exams would need careful planning and the ability to communicate effectively between the team would be of the utmost importance (Debell, 2007). The School Nurse Checklist October 2014 The school nurse checklist was developed by the project leader and was used to identify the current practice in school at that time, and record a baseline of how the service was delivered. Using the checklist revealed that there were no visual aids identifying who the school nurse was, what they looked like, when they were in school, how to contact them and what their role was. The current school nurse room was situated in the school medical room directly opposite the school canteen but there was no reference to the school nurse in this room or any health promotion leaflets or aids. There was no reference to the school nurse on the school website nor in the school prospectus. Heads of year had no access to an electronic or hard copy of the school nurse referral form and many were unaware that one existed. There was also no current diary system in place for booking pupils an appointment with the school nurse. The school confirmed that no health promotion sessions had been held in school previously other than sexual health sessions annually and the year 8 and 9 immunisation programmes. Literature Review October 2014 A literature review was carried out to assess what had already been published to support the benefits of raising the school nurse profile in school and promoting the ‘drop-in’ sessions. The Welsh Government’s Framework for a School Nursing Service in Wales places a specific demand on the school nurse to be a visual and present and a facilitator in meeting the physical, emotional and mental health needs of children and their families (Welsh Government, 2009). The requirement to be a visual practitioner in school is supported by a substantial survey by the British Youth Council (2011) which recorded the views of children and young people on their school nurse. The survey identified that 49% of young people were unsure who their school nurse was and 69% did not have the information about how they could access them for help. The main theme emerging from the survey was the requirement for the school nurse to be visible and well known. The Royal College of Nursing (2008) School Nurse Toolkit and a study by Kay et al. (2006) state that school based ‘drop

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ins’ provide an invaluable service but do need careful planning and advertising to be successful. The specialist community public health nurse in school nursing can maximise their contribution in promoting health in school aged children by analysing the needs of the target group, the required resources and partnerships, the overall cost, and the effectiveness of the health promotion interventions (Ewles and Simnett, 2003). The World Health Organisation’s (2010) 4 year study on health behaviours of school aged children worldwide, identified remarkably consistent health compromising behaviours in 13 to 15 years old. Preventing health compromising behaviours from an early age with appropriate interventions aims to provide young people with the opportunities to develop healthily and is therefore an important aspect of the school nurse role (Welsh Government, 2009). Health compromising behaviours in particular become more prevalent in the above age group who, as they go through puberty, seek new experiences in establishing their own identity (Weare, 2000). Weare found that parents allowed children of this age an increase in autonomy over their behaviours and who they spend their time with out of the school environment. The location of the school nurse room is integral in ensuring privacy and dignity in accessing services discreetly (Royal College of Nursing, 2008).The British Youth Council (2011) study on pupils views of their school nurse recorded that queuing up to visit the school nurse was embarrassing when other pupils could see, compromising privacy. This point was made to the school senior management who agreed to review this and the possibility of relocating the school nurse room to the Learning Resource Centre may be possible in the future. School Nurse Poster The literature review highlighted the need for clear publication and advertising in school of who the school nurse is and where and when they are in school. The project leader met the Health Board’s Medical Photographer and together produced a bilingual poster informing young people and staff of some of the issues the school nurse is able to advise on with a picture of the school nurse and her contact details. The poster has been made available as a pdf to all named school nurses (with their own photograph, name and contact details). The poster produced for this project has been placed on the door of the school nurse’s room to show what the school nurse looks like, which day she is in school and her contact details (Appendix 1). FONS Practice Development Facilitator ‘Shared Values’ exercise Feb 2015 In February 2015, the FoNS Practice Development Facilitator (PDF) was invited to visit the team’s offices for a workshop. After introductions, background to the project and a creative ‘ice breaker’ exercise using Evoke cards, the FoNS PDF facilitated a values and beliefs exercise in relation to the role of the school nurse. La Monica (2005) states that when staff have an opportunity to voice opinions and air problems, it shows that people are involved and care about what they do. Prior to the workshop, the project team (the project leader and another school nurse) had identified 12 members of the school nursing team for Carmarthenshire as the core people needed to support the project and take the final findings and recommendations forward. These individuals were invited to the workshop. The format of the values clarification exercise was firstly individual completion of the sentence stems:

• I believe the purpose of the school nursing service is: • I believe this purpose can be achieved by: • I believe the factors that can help us achieve this purpose are:

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• I believe the factors that hinder us achieving this purpose are: • Other values and beliefs I consider important:

Once individual statements (see Appendix 2) had been shared and discussed in groups of four, it became quickly apparent that many of the nurses shared the same values and beliefs in relation to the purpose of their role and how they could achieve positive outcomes. Achieving lasting and effective change requires the co-operation and involvement of the whole team and not isolated individuals (Belbin, 2010). Mullins (2005) points out that engaging the team from the beginning of change helps combat resistance through early recognition and action. Similarities in barriers to achieving their purpose were also discussed which included pressures of increased caseload, safeguarding priorities and the introduction of new immunisation programmes, which will all place huge pressures on the school nurses role in being a pro-active practitioner. Opportunities to overcome them included shared workload, forward planning, delegating work to support staff and regular updates in monthly meetings. Each group was then invited to express their vision for the School Nursing Service to the other groups in a creative manner. Each group fully embraced this exercise with one group singing a song, one group making a statement of intent and one group sharing their words (for more on this meeting see Jo Odell’s blog 10 February 2015, https://www.fons.org/common-room/blogs). Collectively the team were invited to share the common words and themes that had emerged from their session, these were:

• Nurturing children and families • Protecting and safeguarding children • Providing support for families and each other

The exercise was a resounding success in encouraging the team to individually and collectively engage in sharing the positive and negative aspects of a demanding school nurse caseload and participants were reassured that they shared the same values and beliefs about achieving positive outcomes for children and their families. It was agreed this exercise would be useful to revisit during school nurse meetings at the beginning and ending of the school year and through attending the FoNS Patients First Programme workshops, the project team agreed that they felt confident in facilitating these sessions in the future. Year 9 Pupil Questionnaires Completed A questionnaire was developed in June 2015 by the project team to identify whether pupils knew who their school nurse was and how they would they prefer to access the school nurse, if they had accessed the service, and if so, their experience and lastly their views on how the service could be improved (Appendix 4). Questionnaires were handed out to each registration teacher. They asked the pupils to complete the questionnaires anonymously during registration and hand it in. One hundred and fifty three questionnaires were returned to the project leader from a possible 178 (86% returned). Forty one pupils did not know who their school nurse was (28%) and 111 did. The preferred method of contacting the school nurse was face to face and those that had accessed the service stated it was a positive experience.

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Figure 1

Figure 2

Figure 3

Figure 4

The main themes emerging from pupil comments are as follows:

• “To know where the school nurse is and when she is in “ • “The school nurse to give assemblies on what she does” • “The school nurse details to be on school website” • “The school nurse to deliver sessions in PSHE lessons” • “The school nurse to be always in the same place”

Reflecting on the findings to date the project team were reminded that the school nurse can maximise their contribution in managing change by analysing the needs of the target group, identifying resources and partnerships and acknowledging the effectiveness of the health promotion intervention. There were a couple of surprises in the pupil questionnaires results. The results indicated that 72% knew who their school nurse was, which more than originally thought. One explanation for this high percentage is the timing of the questionnaires, which followed an immunisation programme in school for the whole of the year group in March 2015. This response would also suggest that immunisation programmes in the school setting are an opportunity for pupils to meet their school nurse and might lead them to access the service following that initial contact. Interestingly the preferred method of contact with the school nurse was face to face (67%) compared to texting at 17%, suggesting that although young people use their phones to actively communicate with each other, this is not the method they wish to communicate with their school nurse. This in turn suggests the school nurse needs to be a pro-active, visual and regular practitioner in school in order to build a therapeutic relationship with the pupils and staff in school. Following on from the success of the questionnaire, the project team planned some pupil focus groups to get some more in depth information.

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Planning 1st Focus Group The project team met in order to plan the first focus group which was due to be held at the beginning of the September term 2015. Documentation for parental consent and consent for photos had already been developed and completed by families (Appendix 5) for the seven pupils identified by the head of year. When discussing the format of the focus group, the team were aware that methods used for adults cannot be used in the same manner with children and the team were mindful of the cognitive, linguistic and psychological differences (Gibson, 2012). It was decided that Evoke cards would be used as an ice breaker and a creative session would follow to explore some of the themes from the pupil questionnaires in more detail. The team were keen to be creative. Wolfe (2001) states that young people more fully engage with visual aids in class and if they evoke an emotional response, it will be remembered and recalled for future discussion. The project team agreed to resource the use of flip charts and crayons and various arts and crafts to create an emotional response to the questions being asked and generate further discussion. Deciding where and when to hold the focus group was given a lot of thought and it was agreed with the seven year 9 pupils that the group would meet at lunch time and use one of the registration classes they were familiar with. Gibson (2012) suggests an unfamiliar setting may provoke feelings of anxiety, however Krueger and Casey (2009) argue that when conducting a focus group in school, the researcher should provide a setting that is not reminiscent of the classroom. The 1st Focus Group Session 14th September 2015 Question: “What does your School Nurse do?” The first focus group in school with the seven year 9 pupils, three boys and four girls and three members of the project team, was held on the 14th September 2015. Firstly the pupils were thanked for attending the workshop and the project team introduced themselves. Using a flipchart, the project leader introduced herself as the named school nurse and also introduced the two other members of the project team, the phone number and the day of the drop in clinic was advertised for the group to make a note of. Ground rules to maintain privacy and dignity (Nursing and Midwifery Council, 2008) were discussed and pupils were told that the school nurse would be available to them privately if needed at the end of the session. The most important aspect of the first session was to create a trusting and warm atmosphere between the pupils and the project team in order to facilitate a dialogue between participants. The first exercise used the Evoke cards (http://www.evokecards.com/) as an ice breaker and each pupil was invited to pick a card and share what it made them think of in relation to introducing something about themselves. This exercise went quite well although it took a lot of prompting and involvement of the team initially for the pupils to feel comfortable to speak. The school nurses had decided to use a creative activity to explore the day’s question “What does your School Nurse do?” The group were asked to divide into two smaller groups for this exercise and the girls decided to form group A and the boys group B. Using flipcharts, pens, felts, arts and crafts and glue they were asked to first write down as many words that came to mind when they thought of the words “School Nurse”. Group A wrote down “helps”, “health”, “someone to talk to”, “support” and “there for you”. Group B wrote “jabs”. The groups were then asked to use the art and craft materials and creatively express their answers on flip chart paper. Group A discussed this activity at length (approx 10 minutes) before beginning to draw around their hands and used the arts and crafts, glitter and glue to decorate them and then using bold colour above the illustration wrote “Helping Hands”. The boys collectively agreed, immediately, that they would draw a nurse giving a pupil an injection, with each agreeing who would draw, write and colour in!

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Both groups finished the activity within the allocated time with the school nurse facilitating a discussion between both groups on their posters. All participants were then asked their preference of voucher they would like as a gesture of thanks for participating today, a register was also taken of pupils’ names and tutor group and they all agreed to attend a second focus group planned to take place in January 2016. On reflection the project team agreed the first session had been successful as it was difficult to have predicted how the pupils were going to respond to the exercises. The creative exercises were welcomed by the group and their perception of the question interpreted quite differently. Group A took time to discuss the question in a more holistic manner including emotional and physical health with Group B taking a more clinical approach focusing on the immunisation programme school nurses manage in school. The 2nd Focus Group Session 21st January 2016 Question “How would you like to contact your School Nurse?” The mood of the group was really upbeat and positive for the second meeting. The project team introduced themselves again and set ground rules and displayed contact details and drop in clinic information as before. Participants thanked the project leader for the vouchers they had received previously and also confidently chose their lunch items and began eating and chatting immediately (the pupils had been reticent about eating in front of the project team at the first focus group). The project team again used the Evoke cards as an ice breaker and pupils used humour in their interpretation of the question “pick a card that illustrates how you feel about attending the focus group today”. The participants were more relaxed, confident and talkative and the question for the session was introduced. The group used the flipchart collectively and included each pupil in the discussion facilitated by the project leader. Firstly they discussed accessing the school nurse from a year group point of view. They suggested year group assemblies and Personal, Social and Health Education lessons as opportunities to receive information and updates on topics such as under-age drinking, effects of alcohol, safety, sexual health and emotional health (Welsh Government, 2009). Secondly they were asked how they would like to communicate individually with the school nurse. Pupils discussed using the school email system, which has the option of personal messages, perhaps the school nurse could send a message to the class following a request from a pupil for an appointment. This also led to a discussion on the content of the email and whether the young person would be happy for the teacher to know they were meeting the school nurse. Discussion also included a designated drop in day or afternoon, for each year group, possibly once a month or term to be explored further with school nursing team and school staff. Using text message to inform pupils on a personal level was also discussed in great detail and was agreed a convenient way to communicate. The School Nurse Letterbox was an idea that one male pupil suggested for those children that do not have a mobile phone or access to one whilst in school. The participants explored a safe place for the letterbox to be kept and agreed Hut 2 the Learning Support Centre was most appropriate to place the School Nurse Letterbox. The poster the school nurse has on her door advertising drop in times could also be displayed in each year group corridor in order to raise the profile of the school nurse and to make pupils and staff aware of what she looks like. The session was very productive and the project leader agreed to discuss further with the Head of Year and also agreed to produce more posters for year group corridors. The 3rd Focus Group Session 25th May 2016 At the 3rd session, the pupils seemed the most relaxed they had been so far. Lunch was provided for the pupils who sat together and ate their lunch confidently and comfortably. Ground rules were also

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set including the opportunity to speak to the school nurse privately at the end of the session. The project leader introduced the “School Nurse Rucksack” to the focus group and asked for first impressions. Initial feedback was positive, the pupils said it was easy to see who the bag belonged to with the bright coloured stitching, however, it could have had more badges, keyrings and accessories to make it more current. The project leader then took each item from the bag; the laptop, the phone, house keys, the school book and the lunch box and asked the pupils to discuss what would be the issues young people would have around these items.

• When discussing the laptop, pupils talked about internet security, the stress of theft and damage, the length of time young people use them socially and for school homework. Pupils shared that many of their peers do not go out in the evening but prefer to spend time in their bedrooms talking to each other via the internet. Year 10 and Year 11 have ongoing GCSE coursework and revision leading to many hours each evening spent on their laptops in uncomfortable positions.

• The mobile phone evoked several conversations including, safety, sending pictures, quarrelling with friends, pressure of not having an up to date phone, bullying online, damage, loss and theft.

• The house keys did not evoke conversations of a negative nature instead the pupils discussed increased independence, being trusted by family to have their own key and was seen as a positive and exciting step to further independence from family.

• The school book was discussed and the pupils agreed that school issues created the most amount of stress and anxiety which in turn they felt resulted in eating disorders, quarrels at home and with friends, poor self-esteem, poor sleeping habits and risk taking behaviours. When asked to explore risk taking behaviours further, the focus group added exam stress amongst their peers leads to increase in alcohol and cannabis use, promiscuity due to low self-esteem and self-harming tendencies.

• The lunchbox discussion included all of the above and that many pupils avoid the canteen due to the long queues, embarrassment of free meal status and the desire to avoid other pupils due to quarrels. The focus group added that due to the autonomy given from Year 7 (age 11) upwards, there is no monitoring of what pupils chose to eat and weight gain was an issue for all pupils, both girls and boys.

The project team invited the participants to suggest opportunities they felt the school nurse could address these issues. Suggestions included, school assemblies, information on the school website, advertising drop in sessions and delivering health promotion on these topics through Personal Social and Health Education lessons. The focus group was asked why would they prefer the school nurse to deliver sessions and replies included, “you trust the school nurse to know about your health”, “more comfortable speaking to the school nurse” and “different and a change from the class teacher”. Outcomes There has been a range of outcomes from this project. The school nursing team has engaged with key stakeholders, including school staff, pupils and the wider nursing team, which has given the school nursing team the information and tools needed to take the service further. The work carried out with the school management team to introduce the school nurse and their role resulted in the development of a robust and recordable bi-lingual referral system and the ability to target future interventions. This has created an opportunity to record the number of referrals being made to the school nurse and the concerns raised by teachers and pupils. Since the introduction of referral system, 63 referrals have been made in 18 months equally between year groups. Themes emerging are sexual health, hygiene, medical and emotional wellbeing. The implications for practice

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will be an audit every July of referrals received and a discussion with the team manager on an increase in resources in those areas that have been highlighted in school. Intervention by the school nurse can be targeted to the needs of those pupils. To date, the main referrals for year 9 pupils are emotional wellbeing. This can be shared with the school senior management team and lead to the development of sessions addressing bullying, peer pressure, keeping safe and emotional wellbeing. The main theme emerging from year 11 pupils referrals are sexual health issues and exam stress affecting emotional wellbeing. This would suggest an opportunity for the school nurse to revisit sexual health education sessions with those pupils in that year group. There has been a renewed passion for the role of school nurse and this has been in part a result of the development of a shared vision. Ten members of the Carmarthenshire School Nursing Team participated in the ‘shared beliefs’ exercise. The session was instrumental in developing and sharing the vision of the project with the key members of the school nursing team in order to move the vision forward. In terms of pupils, there have been a number of positive outcomes.

• The referrals recorded for this year group to the school nurse suggest that emotional wellbeing is still the main issue affecting these pupils in school and more work needs to be done in ensuring these pupils access services proactively before reaching a crisis point

• Discussions on project findings with the school management have resulted in the suggestion to hold a “health day” for pupils where the school nurse along with other professionals can provide pupils on advice and information on maintaining their wellbeing and health and how to access help when needed

• The Child Development teacher has invited the school nurse to one of her classes to discuss the role of the school nurse and the qualifications needed

The project findings have been collected and reported to the Director of Nursing and Director of Public Health, Hywel Dda University Health Board who have both given their support to introducing the project to every school nurse. The project leader has put together “The Rucksack toolkit”, in order to support and educate school nurses in the concept of the idea and how to facilitate this change in their schools. The toolkit included bilingual pupil questionnaires, parental consent, a rucksack, lesson plan with pictures of the items and discussion on issues, reflective practice template and a copy of useful websites, articles and references. The project leader will identify key members of the school nursing team in each county who are interested in implementing the project in their school and they will be supported fully by the toolkit and the project team. The project leader has gained a vast amount of knowledge in facilitation, fostering a culture that invites change and leading and facilitating change in practice. The project team have greatly benefitted from the workshop days hosted by Patients First in London which covered a range of topics including professional development. Conclusion The benefits of the project included:

• Introduction of the school nurse poster • Introduction of the school nursing referral form to heads of year and establishing a

professional and accountable referral system • Introduction of bilingual literature available to all members of the team to establish current

practice in individual schools • Opportunity for pupils to participate in a focus group and to discuss the needs of their year

group

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• Networking with partners in the community in raising the school nursing service profile in a professional and sustainable manner

The project has increased overall awareness amongst school staff on the role of the school nurse and the importance of raising the profile of the school nurse in order to support and adhere to the Welsh Government’s Framework for a School Nursing Service for Wales (2009) which set out to develop and maintain a school nursing service for children and young people that is visible, safe, accessible and of a high standard. The introduction of a structured and accountable school nurse referral system has provided the team with an intervention that can be measured and evidenced in planning resources and skills needed for the next school year. The school nurse can maximise their contribution in promoting health in school aged children by analysing the needs of the target group, the required resources and partnerships, the overall cost and the effectiveness of the health promotion interventions. The need to plan resources and education for the year ahead ensures adequate time management in delivering health promotion sessions that are relevant and appropriate to the children, young people and their families. The feedback from pupil questionnaires has provided an unprecedented insight into how the young people in our area wish to access their school nurse and the issues that are affecting them currently. However, conducting the project in school has highlighted the opportunity and need to access the views of each year group at the beginning of the new school year in order to be relevant, to evolve as a service and to remain current. The Patient’s First Programme has given the project team the tools to be able to support and advise other school nurses who would like to raise their profile in their school and communities with the aid of the resources and contacts acquired during the last eighteen months. These include production and introduction of a bilingual poster, bilingual literature, knowledge and experience of facilitation from attending workshop days, requests for the project leader to share findings with the University of Wales, Specialist Community Public Health students in Swansea. Hywel Dda University Health Board newsletter, “Hywel Dda Voice” has asked the project leader to provide a picture and summary of project findings to share with all members of staff and disciplines across the whole of the county. Finally, the project leader has been given an opportunity to introduce “The School Nurse Rucksack” to pupils in order to gain further insight into the current issues affecting pupils in school. Early findings suggest the rucksack can be used as a vehicle to introduce the role of the school nurse with each year group and facilitate a session on “what’s in your rucksack bothering you”. Discussion with the focus group suggests the items in the rucksack can change depending on the year group in question. This will help practice to remain current, visual and delivered in a pro-active manner ensuring early intervention for issues arising for children and young people before the need for crisis management. Acknowledgements The project leaders would like to take the opportunity to thank all the staff working in education and health for their commitment, support and collaboration in the project. To thank the Foundation of Nursing Studies and the Burdett Trust especially Jo Odell for supporting the project as part of the Patients First Programme. References Belbin, R.M. (2010) Team roles at work. 2nd Ed. Oxford: Butterworth-Heinemann. British Youth Council (2011) Our School Nurse. Young People’s views on the role of the school nurse.

London. Mark Allen Publishing Ltd.

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Debell, D. (2007) Public Health Practice & The School Age Population. London. Edward Arnold Ltd. Ewles, L. and Simnett, I. (2003). Promoting Health. A Practical Guide. 5th Ed.Edinburgh. Bailliere

Tindall. Gibson, J. E. (2012). Interviews and focus groups with children: Methods that match children’s

developing competencies. Journal of Family Theory and Review, 4, 148–159. Kay C.M. et al (2006) To what extent are school drop-in clinics meeting pupils' self-identified health

concerns? Health Education Journal September 65(3) 2006 236-251. Krueger, R. A. & Casey, M. A. (eds) (2009). Focus groups: A practical guide for applied research (4th

ed.). Los Angeles, CA: Sage Publications La Monica, E. (2005) Management and Leadership in Nursing and Health Care. 2nd Ed. Hampshire:

Macmillan Mullins, L. (2005) Management and Organisational Behaviour. Prentice Hall. Nursing and Midwifery Council (2008). Code of Conduct . London :NMC Royal College of Nursing. (2008). An RCN toolkit for School Nurses. London. Royal College of Nursing. Taylor S & Field D. (2007) Sociology of Health & Health Care. 4th Ed Oxford. Blackwell Publishing. Weare, K. (2000) Promoting Mental, Emotional and Social Health: A whole school approach.

Routledge. New York. Welsh Government. (2009). Framework for a School Nursing Service for Wales. Cardiff. Welsh

Government. Welsh Government. (2011) Together for Health: A five year vision for the NHS in Wales. Cardiff.

Welsh Government. Wolfe, P (2001) Brain Matters: Translating the Research to Classroom Practice. ASCD. Alexandria. World Health Organisation.(2010) Health Behaviour in School Aged Children, International Report

from the 2009/2010 Survey into Social Determinants of health and well being among young people. Copenhagen, WHO Regional Office for Europe, 2012 .

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Appendix 1: The School Nurse Poster

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Appendix 2: Bilingual Referral Form

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Appendix 3: Shared Values and Beliefs I believe the purpose of the school nursing service is:

I believe this purpose can be achieved by:

I believe the factors that can help us achieve this purpose are:

I believe the factors that hinder us achieving this purpose are:

Other values and beliefs I consider important:

To support the emotional and physical health needs of our pupils in our schools.

Good Team Understanding what pupils want from us Setting targets

Being able to listen Having the time to listen Knowing where to get help

Increased demands on our service with vacant posts Not having time to do what we need to Other professionals telling us what our job is

Respect Honesty Caring

To prioritise the needs of young people Identify health needs Support young people health and well being

Use research based evidence to provide an appropriate service Being available

Team working Share information Communicating with young people

Limited resources Time constraints Varied responsibilities

Being able to communicate with young people. Having an understanding of emotional wellbeing

To care and protect children and young people’s physical, emotional and mental health by identifying any problems they may have and help to combat or tackle those problems in order that they may achieve the best possible health

Working together as a team and by working closely with the school and other agencies through good communication and by having passion in our purpose

Good communication Accurate record keeping Making ourselves available to children and young people and our schools Building good relationships with each other

Time Lack of resources

Honesty Integrity

Promote a safe and healthy life Keep vulnerable children safe

Health promotion Education Immunisations Follow up Accident and Emergency attendances Liaise with agencies and information sharing Listening to shared concerns Lessons in school Immunisations

Manageable caseloads Full quota of staff Good communication between different agencies

Lack of time Lack of staff due to covering each other caseloads Poor communication

Team work Sense of humour Flexibility Honesty

To support families through advising and signposting to specialist services

Working in a transparent manner with children and their families

Time Resources Communication

Time Resources Different ideas

Trust Communication respect

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To support children and their families in physical and emotional wellbeing

Working together

School Nursing team working together Support from other professionals Maintaining professional standards

Poor systems in place Documentation and filing Caseload sizes Looked After Children numbers Lack of time

Integrity Honesty Supporting each other and being supported

To provide equal access to all school aged children providing health education, promotion, support and ensure each child’s health needs are met.

Working together as a team Keeping updated on practice Willingness to change Happy to be flexible

Education Supporting each other

Lack of funding School nurse are not valued by other professionals Ignored at University level

Every child matters Equality Advocacy

To enhance the lives of the children and families we work with to ultimately give them a healthy start in life

Working together and attending study says.

Empathy Determination Belief Diligence Good sense of humour

Time constraints Lack of public awareness of the role Demands are ever increasing yearly with no extra staff or time

Family Friends My faith

Continued child surveillance programme and protecting and supporting children and teenagers

Working together Regular morning updates Clear communication

Planning ahead Clear communication Non judgemental attitude

Heavy workloads Passive listening Work ethics

Equality Approachable and caring members of staff

To provide a link between the pupil, family and health. Involving emotional and physical health Realising that health is as individual as the child and it means something different to everyone

Being open, transparent and approachable. Non judgemental

Time Support Reflection Fulfilment

Time Personal values Other work commitments Lack of knowledge and skills

To always treat people equally To allow everyone the same opportunities To be honest with others and yourself

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Appendix 4: Pupil Questionnaire

1. Do you know who your School Nurse is? Yes/No

Any comments:

2. How would you prefer to access the School Nurse? Telephone…….. Email………..

Text…………. School………….. Other (please detail) ……….……………….

Any comments:

3. Have you accessed the School Nursing Service for support or information? Yes/No

Any comments:

4. If yes, how would you rate your experience? Excellent … Good…. Satisfactory……

Average………….. Poor…………

Any comments:

5. In your view, how could the School Nursing Service improve what you know about the work of

the School Nurse and how to access the School Nurse?

Any comments:

We appreciate your time in completing and returning this questionnaire.

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Appendix 5: Focus Group Letter and Consent