Children's emotional wellbeing is suffering and the extent of mental health issues in the young has reached crisis levels. The COVID-19 pandemic has led to an increased demand for child and adolescent mental health services and generally many a young person's psychological wellbeing has been challenged in these continued difficult times. Early intervention has been recognised as a positive step towards wellbeing and needs to become more of a priority in order to prevent future generations experiencing crippling mental health disorders. The RCN Foundation recognised these challenges and commissioned a scoping review of ‘Nursing-led Interventions to support the psychological and emotional wellbeing of children and young people’ in collaboration with Sheffield Hallam University.
The National Wellbeing Survey in 2018 reported higher levels of mental ill health and loneliness in 16 to 24-year-olds than in any other age group (Jones and Randall, 2018). However, little detail is provided, and under 16-year-olds were not included. The most recent British surveys of children and young people aged 5–15 years in 1999 and 2004 carried out by the Office for National Stiatistics (the British Child and Adolescent Mental Health Surveys, or B-CAMHS) found that 10% had a clinically diagnosable mental disorder (Ford et al, 2003; Green et al, 2005). In these two surveys, the prevalence of anxiety disorders was 2–3%, depression 0.9%, conduct disorder 4.5–5%, hyperkinetic disorder (severe ADHD) 1.5%, and autism spectrum disorders 0.9%. Rarer disorders including selective mutism, eating disorders and tic disorders occurred in 0.4% of children.
Self-harm in young people was also found to be highly prevalent. In the 2004 B-CAMHS survey, the rate of self-harm in 5–10-year-olds without a psychiatric diagnosis was 0.8%, rising to 6.2% in those with an anxiety disorder and 7.5% among the group of children with hyperkinetic disorder, conduct disorder or one of the less common disorders. Suicide is the leading cause of death in young people. The suicide rate among 10–19-year-olds is 2.2 per 100 000. This rate is higher in males (3.14 compared with 1.30 for females) and in older adolescents (4.04 among 15–19-year-olds compared with 0.34 among 10–14-year-olds) (Windfuhr et al, 2013).
There has been a serious deterioration in children and young people's mental health since the pandemic. Sarah (not her real name), whose teenage daughter relapsed into anorexia during the pandemic, recounts her experience:
‘The pandemic has been devastating for my daughter and for our family. She has anorexia and was discharged from an inpatient unit last year, but the disruption to her normal routines and socialising really affected her recovery. She was spending a lot less time doing the things she enjoys and a lot more time alone with her thoughts. Unfortunately, she relapsed, becoming so unwell she was admitted to hospital and sectioned. After 72 days in hospital with no specialist eating disorder bed becoming available, we brought her home where I am now tube-feeding her daily. My daughter urgently needs specialist help for this life-threatening illness, but because of increased demand services are completely overwhelmed. It's a terrifying situation to be in’.
(Royal College of Psychiatrists [RCP], 2021: 1)
Rates of probable mental disorder have increased since 2017. In 2020, one in six (16.0%) children aged 5 to 16 years were identified as having a probable mental disorder, increasing from one in nine (10.8%) in 2017. The increase was evident in both boys and girls. The likelihood of a probable mental disorder increased with age, with a noticeable difference in gender for the older age group (17 to 22 years); 27.2% of young women and 13.3% of young men were identified as having a probable mental disorder in 2020.
The RCP's analysis found that 80 226 more children and young people were referred to CYP mental health services between April and December 2020, up by 28% on 2019, to 372 438. 600 628 more treatment sessions were given to children and young people, up by a fifth on 2019 to 3.58 million. 18 269 children and young people needed urgent or emergency crisis care – including assessments to see if someone needs to be sectioned because they or others are at harm – an increase of 18% on 2019, to 18 269. Dr Bernadka Dubicka, chair of the child and adolescent faculty at the RCP, said:
‘Our children and young people are bearing the brunt of the mental health crisis caused by the pandemic and are at risk of lifelong mental illness. As a frontline psychiatrist I've seen the devastating effect that school closures, disrupted friendships and the uncertainty caused by the pandemic have had on the mental health of our children and young people. Services were already struggling to cope with the number of children needing help before the pandemic hit, and they risk being overrun unless government ensures the promised money reaches the frontline quickly’.
(RCP, 2021: 1)
About a third of existing services for children and young people are inadequate. The CQC in 2020 rated specialist mental health services for children and young people as 6% inadequate, 27% requires improvement, 57% good and 10% outstanding. There is an urgent need for models of care to be transformed to meet need. The scoping review is part of the process of identifying and disseminating good practice in mental health services for children and young people.
Scoping literature review
A literature review was undertaken to identify the nature and extent of recent literature regarding nurse-led interventions in the UK, excellence in practice and gaps in provision. An initial search yielded 7 999 results but only seven UK-based studies were identified for inclusion, before an additional 11 were included from other countries deemed relevant due to comparable health infrastructures. The 18 studies varied considerably in regard to the type of intervention and range of nursing roles, as well as the level of nursing involvement and how or what outcomes were measured. The synthesis of heterogenous papers is challenging in any literature review, and here, the identification and agreement of what should be considered current ‘best nursing-led practice’ is a particularly acute challenge for this review.
The limited number of studies resulted from the rejection of many studies due to minimal or no involvement of nurses in the research itself. It is possible that nurses, given increased demands on service, cutbacks on funding and smaller workforces, do not have the time or capacity to add research to their workload.
A key recommendation is for researchers to identify appropriate methods in which they can include nurses directly into the development and implementation of research design. This would not only allow nurses to immediately feed back the feasibility of the proposed intervention but would allow nurses a greater opportunity to have their lived experiences heard, and to collaborate more in the development of evidence-based practice, potentially increasing engagement and efficacy overall. Another criterion which made papers ineligible for inclusion in the review was a lack of explicit information regarding an intervention, such as reviews, editorials, opinion pieces or case studies. Many papers appeared to reference possible interventions, but could not be substantiated by academic literature, something potentially common place among healthcare professions not authored by medical doctors. This suggests that nurse-led interventions are being implemented, but the practice is not being clearly communicated through academic pathways such as scientific journals, or the work is not meeting the level of necessary academic rigour, which raises questions about the scientific validity of apparent interventions. These are fairly superficial assumptions, and must be taken with the view that further research is needed; including clarity into the implementation of nurse-led interventions to ensure it is better understood how these are created, evaluated and communicated to nursing staff.
Health visitors and school nurses need to seize the moment in their contributions to research studies. Many qualified SCPHNs (Specialist Community Public Health Nurses) have postgraduate qualifications and are in an ideal position to plan, implement and evaluate mental health interventions.
Data of the large number of referrals (NHS Digital, 2018) and diagnoses for children and young people in the UK highlight the increase of help-seeking behaviour and demand on services in recent years. Much of the interventional research identified in this literature review focuses on the mental health assessment, screening and consultation tools carried out by nurses. While the reviewers have included these tools under the definition of an intervention, it is possible that an increase in efficiency of these preventive measures could also lead to the increase in referrals seen by NHS Digital (2018). However, what could be more pertinent is a need for more reactive interventions, ones that target the symptoms or causes of mental ill-health or poor wellbeing, not just the identification of it. For example, the Royal College of Psychiatrists (Campbell, 2018), while pleased to see more young people are being referred, state they are concerned the workforce is too small to treat such a large group. Effective interventions are still a necessity, and there appears to be a paucity of these. While this literature review shows nursing staff are well placed to screen and identify mental ill health, it may be more pertinent to look at interventions that can efficiently target clinical symptoms and diagnosed conditions, given a rise in referrals will mean a rise in demand, and a need for more effective interventions if the workforce is too small. SCPHN practitioners could deliver universal interventions which contribute to recovery from mental ill health. An example would be education in cognitive behavioural therapy.
The majority of studies included in this review are preventive interventions, as opposed to reactive. This could be due to school nurses being the most frequently occurring type of nurse involved in the interventions found in the literature review. The nature of a school nurse role is also likely to be more proactive and educational (Croghan et al, 2004) considering the wider-teaching environment in which they are situated. School nurses could also be considered to be in a position which facilitates more proactive interventions and has the advantage of unique access to a specific community. Overall, this suggests that the type of nurse and setting is likely to influence the type of intervention reported. On this basis, if more research was conducted by other types of nurses, such as paediatric or mental health nurses, the types of intervention reported may be more diverse and equitable.
Results appeared to suggest that digital interventions (such as questionnaires delivered online or web-based cognitive behavioural therapy [CBT] interventions) were concurrent with a higher recruitment of participants, likely due to the efficiency of digital interventions in contrast to face-to-face interventions that are staff-, and therefore time-intensive. Given time pressures for mental health services due to small workforces struggling to meet demand from high numbers of referrals, this could be suggestive of a change in how interventions could be, or are being, provided.
More digital interventions, either for the screening or treatment of conditions, could potentially help alleviate some of this pressure if it leads to more children and young people being assessed and/or treated faster. A beneficial factor in nursing interventions is often the therapeutic relationship between practitioner and patient (Roberts et al, 2015); an alliance likely absent in digital interventions. However, studies comparing face-to-face and internet-delivered mental health interventions, such as CBT, have demonstrated comparable results in symptom reduction for adults (Andersson et al, 2014).
With so many young people more engaged with technology and the internet, it might be the most suitable method for access to this population. It could therefore be beneficial for future research to identify if similar comparisons exist between face-to-face and digital nurse-led interventions for children and young people. Even so, research has found digital-based psychological interventions are perceived as less favourable to face-to-face therapy by therapists, even though results are equivocal (Rochlen et al, 2004). It could be that similar barriers are experienced by nurses, therefore research should also focus on the perceived benefits and limitations identified by both nurses and young people.
Delphi study
Informed by the literature review, a two part modified Delphi study was subsequently undertaken. The Delphi method is a proven method of investigation that uses an expert panel to reach a consensus via a number of iterations (Baker et al, 2006). Delphi is characterised as a method for managing effective group communications and allows a group of individuals collectively to deal with a complex problem (Tinstone and Murray, 1975).
Methods
Ethical approval was granted for the Delphi study and the survey was sent out across the UK. The Round 1 survey was an open-ended, semi-structured questionnaire which, after piloting, was circulated by email and made available as an online survey. Nurses had to be currently working with young people's emotional and psychological wellbeing and were recruited using professional networks. 244 questionnaires were returned with 101 holding useful data for analysis. 84 codes for different interventions were identified including CBT, dialectical behavioural therapy (DBT), family and systemic approaches, solution focused therapy (SFT), mindfulness and relaxation, motivational interviewing/motivational enhancement therapy, behavioural management/incredible years, therapeutic relations/counselling, group interventions and medication.
Findings
Survey responses confirmed the fundamental importance of the therapeutic relationship. They also suggested that nurse-led pre-crisis and early interventions which addressed the mental health and emotional wellbeing needs of children and young people were being extensively utilised. All countries and all regions appeared to have primarily community-based services with school in-reach perceived to be highly beneficial. As a review team, we were deeply impressed by the range and scope of interventions but require more evidence about the breadth and depth of intervention and whether the key components of the analysis of the nurse activity should be a guide for training and development opportunities.
The early interventions typically targeted levels of resilience, emotional regulation and the prevention of ongoing mental health problems. Respondents viewed these early interventions as effective but often encountered organisational and practical challenges including access to training and ongoing supervision. These were perceived to adversely affect the effectiveness of their treatment.
Nurses had a good awareness of a range of evidence-based interventions with cognitive behavioural therapy (CBT) featuring most heavily, typically being seen as a routine and effective intervention. The review team consider that based on our findings, CBT should be a core and first line intervention for those involved in the psychological wellbeing of young people. This would have implications for strengthening preregistration nurse training. It was observed that core skills should be included in preregistration training.
Digital resources were represented in the literature review and the Delphi study. These included apps and e-clinics and were seen by a number of responders as useful in-reaching to young people and also familiar to them, which might encourage use. The main intervention was cognitive- and behaviour-based. Despite some concerns about the quality of the therapeutic alliance, responders wished for more of these to be available to them.
The Family Network Partnerships (FNP) model was popular in Scotland, as was the Solihull Approach across England. The latter was posited for inclusion in preregistration nurse training, as were CBT and early signs recognition. Other interventions that are worthy of note are DBT, motivational interviewing, mindfulness-based approaches and the emerging use of outside space. Training and education in all these approaches would strengthen the input of SCPHN practitioners to the mental health agenda.
Additional training, to augment preregistration education in the therapeutic alliance, was viewed as important to the delivery of high quality, nurse-led interventions. However, while many nurses had received some form of intervention-based CPD training, the pattern was highly variable and others were reliant on their basic nurse-training and subsequent practice experience alone.
Despite the difficulties in accessing training, ring-fencing time to deliver evidence-based therapies and receiving clinical supervision, the nurses who responded to this survey remained committed to the profession and to meeting the needs of the children and young people that they worked with.
Recommendations for practice and research
Based on a synthesis of the findings from the literature review and Delphi study, the following recommendations were made:
- Nurses should be involved in any research that makes recommendations for their practice, and identified explicitly to aid clarity and communication between research and current practice.
- Consideration should be given to structuring a UK-wide continuing professional development module/programme as outlined in the training discussion.
- If a UK-wide core module for nurse-led young people's psychological wellbeing is initiated, then this should be accompanied by a research study into its effectiveness.
- The expansion of the Solihull or Family Nurse Partnership models should be considered, whichever approach is recommended in the relevant country.
- Resources should be made available for nurses to train in effective models for young people's mental health and wellbeing, in particular cognitive behavioural therapy interventions.
- Some attention would be worthwhile on deciding on a limited data set of assessment schedules for young people's mental health and wellbeing.
- A review of clinical supervision arrangement for staff working in young people's mental health and wellbeing would be informative.
- Research is needed into pathways to ensure that they become more efficient and streamlined and for interventions to become more efficiently delivered online.
- Future research is warranted to identify whether time is a particular issue, and methods to manage this.
- Nurses should be given better, more evidence-based support and consulted appropriately about their roles.
Conclusions
Inequalities exist in the delivery of nurse-led mental health interventions for children and young people. The plethora of programmes of care is heavily dependent on the skills of individual practitioners. There is no uniform delivery of service which affects the quality of what is offered. This could make the difference to a child's outcomes and is unacceptable. Urgent action is required to develop national guidelines for nurse-led mental health interventions for children and young people. The evidence base for what works requires further priority. Training and education for practitioners are necessary to meet need. Without this transformation in the way mental health services are delivered, future generations are unlikely to reach their potential or have the resilience and coping capacity to meet life's challenges.