Back to school: how school nurses have coped with new-term challenges
Return to classrooms reduces concern about childrens physical and mental health, but school nurses have less access and must find new ways to make contact
- Childrens emotional health is being affected by worries over the pandemic and changes it has wrought in schools
- The School and Public Health Nurses Association reports members have seen a significant rise in safeguarding and child protection cases
- Personal protective equipment worn by staff can sometimes act as a barrier to building relationships with pupils
Millions of UK children returned to the classroom in September as schools reopened amid the continuing COVID-19 pandemic.
Since March, many had experienced little contact with the outside
Return to classrooms reduces concern about children’s physical and mental health, but school nurses have less access and must find new ways to make contact
- Children’s emotional health is being affected by worries over the pandemic and changes it has wrought in schools
- The School and Public Health Nurses Association reports members have seen a ‘significant rise’ in safeguarding and child protection cases
- Personal protective equipment worn by staff can sometimes act as a ‘barrier to building relationships with pupils’
Millions of UK children returned to the classroom in September as schools reopened amid the continuing COVID-19 pandemic.
Since March, many had experienced little contact with the outside world, prompting fears from school nurses about children’s physical and mental health as well as safeguarding issues.
In September the Local Government Association (LGA) reported that referrals to children’s social care teams had fallen by nearly one fifth since the start of the pandemic, while the number taken into care was down one third.
drop in referrals to children’s social care teams from April to June
(Source: Local Government Association)
Pandemic has had devastating effect on some home environments
LGA children and young people board chair Judith Blake says the pandemic has had a devastating effect on some families and home environments – and councils are braced for a ‘significant rise’ in referrals.
The early signs are that these concerns are being borne out. The School and Public Health Nurses Association (SAPHNA) reports that its members have seen a ‘significant rise’ in safeguarding and child protection cases.
Doncaster school nursing service lead Jayne Ashby says an increase in domestic abuse has been a key driver.
‘You always see a rise at this time of year after the summer holidays, but what has happened in the past weeks outstrips that.
‘The cases are also more serious – children not being in school has meant situations had escalated further than they normally would have before being identified.’
Anxiety and low level mental health and emotional concerns
She also says her team is seeing an increase in ‘anxiety and low level mental health and emotional concerns’.
Some of this is related to the pandemic but some is linked to the return to school and things such as bullying and exam stress, she believes.
Anne Tomkinson, a school nurse based in Warwickshire, agrees the emotional health of children is being affected in many different ways.
‘Many pupils are pleased to be back at school and among their friends, but we are seeing quite high levels of anxiety. Some pupils are worried about the virus and feel unsettled by the changed environment at school.’
This has been marked among secondary-age pupils but is also being seen among those in year six at the end of primary school, she says.
Survey found main concerns were loneliness, lack of motivation and anxiety
It is an issue that worries the charity YoungMinds. An online survey by the charity in the summer that obtained responses from over 2,000 people aged 13-25 who had sought mental health support in the past found eight in ten had experienced a deterioration in their mental health during the pandemic.
The survey found loneliness, lack of motivation and anxiety were the main concerns and these were manifesting themselves in eating disorders and self-harm in some cases.
8 in 10
young people who had sought mental health support in the past have experienced a deterioration in their mental health during the pandemic
Of those who had been accessing mental health support before the pandemic, nearly one in three (31%) found they could no longer obtain the support when they needed it.
Need for dedicated mental health support funding in schools
The findings prompted YoungMinds to write to the government ahead of the start of the school term to ask for dedicated funding for mental health support in schools, with a particular stress on pupils in the most disadvantaged areas.
An extra £1 billion has been provided to schools for 2020-21, but none of it is being ring-fenced for mental health support.
‘In these exceptional circumstances, schools need to be able to act quickly, prioritise well-being and provide pastoral support to all students who need it’
Emma Thomas, chief executive of YoungMinds charity
YoungMinds chief executive Emma Thomas would like to see additional school counselling and online support offered to help school nurses and child and adolescent mental health services meet the needs of pupils who are struggling.
‘In these exceptional circumstances, schools need to be able to act quickly, prioritise well-being and provide pastoral support to all students who need it,’ she says.
‘There is a danger that many young people will fall through the net and not receive support that would enable them to adjust back to school successfully. Students will not be able to learn until they are ready emotionally.’
Barriers to supporting children in schools
School nurse Ms Tomkinson says there are signs that extra support is being put in place outside of school for children who need it, but she warns there are a number of barriers to supporting children in schools.
‘We are finding it quite challenging to see pupils at times. Some schools do not want to let us come on site or in others we have referrals but then find the year group is having to isolate.
‘We are trying to find creative solutions – using other venues such as children’s centres and doing walk-and-talks.
‘But access to pupils is narrowing and I think will continue to do so as winter progresses. That is a concern if we are going to support pupils through this difficult time.’
Ms Tomkinson also says personal protective equipment (PPE) requirements can act as a ‘barrier to building relationships with pupils’.
The guidance requires school nurses to wear full PPE if in close proximity to a child, but she says some schools are insisting on it all the time.
‘You can’t see the facial expression or touch someone’s arm to show empathy.’
It is a sentiment that has been echoed by other school nurses, according to SAPHNA.
The way appointments are organised has also been changed in many places, with a greater reliance on bookings than drop-in services.
A chat with the school nurse – by text message
Since the start of term the school nursing service in Calderdale, West Yorkshire, has not experienced the usual rise in children coming forward with mental health problems or referrals for safeguarding typically seen following the summer break.
School nursing team lead Meinir Smith believes Calderdale’s new digital ChatHealth service has had a big role to play.
It was launched in April, just after lockdown was announced, and is aimed at parents of primary school age children and pupils in secondary school.
Ms Smith says it has proved invaluable. ‘We saw a lot of activity during lockdown, but then it quietened down once the restrictions started to ease.
Users are guaranteed a response within 24 hours or less
‘I think that reflected how difficult lockdown was – children were not seeing their friends and parents were worried about keeping their children motivated and helping them develop a routine.
‘Users are guaranteed a response within 24 hours, but for most it is much quicker.
‘Some have wanted follow-up phone calls, while for others we will provide text responses and point them to other services that can provide help.
‘We saw things get quieter as restrictions were lifted – but the fact we were able to provide that support during lockdown has helped.’
More appointment-based approach
Sarah Ward, one of the school nurses in the team, agrees. ‘We have found children are pretty resilient. They worry about the virus but many are glad to be back at school, among their friends and taking part in activities.
‘The pandemic has changed the way we work. We are no longer doing drop-ins at schools and have instead moved to a more appointment-based approach for things like holistic health assessments.
‘Meetings with teachers and parents can be done online.’
1 in 3
young people receiving mental health support prior to the pandemic have been denied it since April
SAPHNA chief executive Sharon White says nurses are having to be flexible – although she is beginning to hear of some drop-in services restarting as the impact of the pandemic becomes clear.
Behavioural issues such as pupils not settling or being disruptive
‘Many pupils are anxious and depressed – there has been a lot of self-harm. In younger pupils we are seeing a lot of behavioural issues – pupils not settling or being disruptive.’
But in some areas school nurses are taking on extra responsibilities too alongside meeting these additional needs, she says.
‘They are spending time helping schools with infection prevention and control, advising them on which pupils and staff should be isolating when there are confirmed cases as well as advising re track and trace.
Difficulties with testing force some staff and pupils to isolate for a long time before receiving results
‘We have seen some variation – in some places whole year groups are being sent home, in others it is more specific. Much depends on the environment and implemented systems of control of the school.
‘In some areas school nurses have been specifically commissioned to do this but in others they are doing it as part of their existing duties.’
She says difficulties accessing testing are ‘causing real problems’, with staff and pupils forced to isolate at home for a long time before they receive results.
Creative solutions enable regular vaccinations to go ahead
Backlogs in vaccinations are an added complication, she says, with some pupils still waiting for immunisations such as the HPV jab, while the expanded flu vaccination campaign this winter will see year seven pupils offered the jab.
She says this is leading to some ‘creative solutions’ being introduced, with marquees being set up in school fields and mobile units being brought in.
In Leicester, the immunisations service used the local football stadium to do some catch up work, while in the Isle of Wight the school nursing service ran drive-through clinics. ‘It is encouraging to see,’ says Ms White.
Face-to-face support during summer lockdown
Throughout the summer, school nurses in Northamptonshire offered secondary school pupils struggling with low-level emotional problems the opportunity of face-to-face support.
School nurse Eva Trkulja says: ‘Lockdown caused a lot of anxiety and distress, so we began to think about ways we could offer face-to-face support to these pupils. We heard that other areas had started exploring walk-and-talk sessions and thought this could be a good solution.
‘You cannot underestimate the importance of face-to-face contact. You can pick up important cues and it can really make a difference to the relationship between nurse and pupil.
Walk-and-talk sessions in the fresh air
‘We spent the time talking through their worries, supporting with problem-solving, discussing coping strategies such as mindfulness techniques and self-care, such as how to sleep better, the importance of eating well and physical activity.’
The offer of a walk-and-talk was only made to pupils with low-level emotional health problems.
Anyone with a history of abuse, drug-taking or alcohol abuse was not eligible for the support and instead they would be referred to social services and child mental health services.
A risk assessment was also undertaken before meetings – this included gaining parental consent and checking that no one in the household had COVID-19 symptoms.
Positive feedback from young people and families
Pupils have received follow-up calls and support as well as being offered further walk-and-talk sessions if needed.
Ms Trkulja says feedback from the young people and families was positive. ‘They have worked well. Being outside in the fresh air, among nature, is very calming and is a great way to engage with the pupils who needed our help.
‘It brought a new dimension to the support we provide. It is a valuable environment to use to engage in a calm manner that we previously may have overlooked, as we traditionally meet with pupils indoors.’
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