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Unpacking a rucksack of worries with the school nurse

With rising numbers of 13-14 year olds being referred to child and adolescent mental health services, one nurse has launched an initiative to overturn the statistics

With rising numbers of 13-14 year olds being referred to child and adolescent mental health services, one nurse has launched an initiative to overturn the statistics

How to encourage young people to present their issues to the school nurse is a complex issue. But one school nurse has come up with a deceptively simple answer after undertaking a project to increase recognition and engagement with the service – school nurses should carry around a special rucksack as their ‘calling card’.

The school nurse is Jacqueline Jones, of Hywel Dda University Health Board, who works with secondary, special and primary schools in Camarthenshire, south west Wales.


School nurse Jacqueline Jones

She explained: ‘While on the specialist community public health nurse degree training, I was astounded by the number of emotional well-being issues. I wanted to spend time examining this, so I went to child and adolescent mental health services (CAMHS) to find out where the referrals were coming from, who they were coming from, and what was being done about them.’

Missing opportunity

Ms Jones began studying referrals to Hywel Dda CAMHS office and found 52% were from GPs and 12% from school nurses, according to figures produced by the health board for 2013. 

‘I thought, children are reaching a crisis, being taken to the GP to CAMHS, but where was the school nurse service? Have we missed an opportunity to be proactive?’

The most prevalent age group also caught her attention as there was a significant increase in referrals of 13 and 14 year olds.

Further research showed this was a national issue, as the numbers for self-harming and high risk taking behaviour were highest among children in this age group. However, it is also a global problem. A four-year study of school-aged children by the World Health Organization, published in 2010, found consistent compromising health behaviours among 13 and 14 year olds. 

This clinched Ms Jones’s decision to focus on year 9s, an age group shown to be impulsive, prone to making bad health decisions and to exhibiting high risk-taking behaviour.

‘I looked at how school nurses deliver their drop-ins there was little evidence of successful drop-ins and of a nurse being in school'

She then asked herself how might school nurses in Hywel Dda reach out to this group?

‘I looked at how school nurses deliver their drop-ins there was little evidence of successful drop-ins and of a nurse being in school. There was no picture displayed at school, there was no timetable of when they would be there.

‘Then I thought I need to look at my own drop-in. When we walk into school with a yellow sharps box the pupils know instantly they are going to have an injection. I wondered how I could provide instant recognition in a more positive way.


One of the posters
​​​​​​from the campaign

‘I took the sharps box into the year 9 class and I asked them to write down all of the negative coping mechanisms they might use. The first thing I did was to get them to write down some of the issues that would cause them anxiety, at home or in school. The main themes were exam stress, issues with home - either boundaries or separation - and the lunch box as there were a lot of responses about healthy lifestyles or unhealthy choices.

‘There were a few themes coming through – exams, school work, bullying – and then I asked them who they speak to. In their replies there was very little referrals to the school nurse.’

Getting the message across

She began thinking about how to deliver a positive message to encourage children to use the school nursing service.

 ‘Then one morning I noticed my daughter leaving for school wearing a rucksack that was chock-a-block. It was too heavy, she wasn’t wearing it properly and she was worried about missing the bus.

‘I made her stop and I said “Look, is your rucksack organised? You seem to have too many books in it.” And she went, “Oh, I haven’t got time mum”.'

We readjusted the straps and, as she walked out of the door, it hit me: “What in your rucksack is bothering you?”

Ms Jones now leads a project, supported by the Foundation of Nursing Studies’ Patients First Programme in partnership with the Burdett Trust for Nursing, to build on this idea and raise the profile of the school nurse by engaging pupils and key stakeholders.

A staff development session was carried out and a presentation held.

The five items in the rucksack

  • A school book representing school work and exam pressure
  • A lunch box: healthy and unhealthy lifestyles and eating disorders
  • House keys: issues at home and conflict with parents and guardians
  • A mobile phone: friendship concerns, bullying
  • Laptop: internet security issues and negative aspects of social media

A questionnaire was used to discover how pupils would like to contact their school nurse and the issues they would like to discuss. Questionnaires for year 9s to complete anonymously were handed out during registration – 153 of the total 178 questionnaires were completed. Results found that 20% of the pupils had used the school nursing service, 47% of these reported a good experience and 31% rated it as excellent.

Two-part aim

The school nurse was given the rucksack to pilot to help pupils recognise their school nurse. Focus groups were held in one comprehensive school and pupils were asked about what was in the rucksack which led to advice and support about what school nurses can offer. Pupils were positive and the regular school nurse reported that more pupils attended her drop-in clinic.

The project has two aims – to raise visibility of the school nurse and encourage uptake of the service. ‘When they know who the school nurse is, what they look like, where they are, and you’re consistently there, that’s what empowers children to decide that they are going to tell you something,’ said Ms Jones.

Her solution was to advertise the presence of the school nurse with posters in school. All school nurses have their own version of the poster featuring their photograph and details of how to contact them. The poster is placed on the door of the school nurse’s room identifying what the nurse looks like, the day they are in school and how to contact them.

There are now plans for research with Swansea University to evaluate the project’s success in increasing uptake of the service.


Anne Horner is a freelance journalist

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