Prior to the COVID-19 pandemic, it was estimated worldwide that 10–20% of children experience mental health difficulties (Kieling et al, 2011; Bor et al, 2014) and in an average sized classroom, three children struggled with poor mental health having a detrimental effect on their education, social and physical development and ultimately their overall wellbeing (Barry et al, 2013; Neagle, 2018). However, the unintended consequences of the two national COVID-19 lockdowns – disruption to education resulting in reduced and remote learning, increased isolation, loneliness, and reduced access to supportive professionals – that children and young people have experienced since March 2020, have increased poor mental health and wellbeing (Senedd Commission, 2020; Children's Commissioner for Wales, 2021). SCPHN school nurses play an integral role to identify and provide appropriate support and interventions when a child or young person struggles with poor mental health. Although this paper relates to Wales and Welsh policy, it is important to note that the findings are transferable and therefore pertinent to school nursing practice across the UK.
Background
The mental health crisis is costing Wales over £7.2 billion per year (Mental Health Foundation, 2016), including both health-care costs and welfare expenses, with mental health reasons accountable for 40% of benefit claims. Poor mental health is thus a recognised public health concern (Detels, 2015) due to financial costs, high incidence and prevalence, the widespread detrimental effect on other areas of health and social care and the identified benefits of early intervention (Barry et al, 2013; Vostanis et al, 2013; Bor et al, 2014; Detels, 2015; Mental Health Foundation, 2016). The COVID-19 pandemic has also illustrated and widened inequalities. Socio-economic circumstances, quality of housing, family structure and resources have impacted on lived experience of children and young people, and those in lower socio-economic groups were affected the most (Public Health Wales [PHW], 2020). Prior to the pandemic, one in ten children in the United Kingdom (UK) recognised having a diagnosable mental health disorder (Jones, 2013) with half of adults who experience poor mental health reporting that their difficulties started before they turned 14 years of age (Kessler et al, 2005; World Health Organisation [WHO], 2020). For that reason, it is recognised that the pandemic will have a long-term detrimental effect on children and young people's mental health into adulthood. Those adults with severe or chronic poor mental health are likely to die 10 years earlier than those of the general public (Puvill et al, 2016). Therefore, as key contributors to the health and development of children and young people, it is vital for SCPHN school nurses to recognise the importance of early intervention with regards to emotional health and wellbeing (EHWB) for the wellbeing of the adults these children become (Vostanis et al, 2013).
Policy analysis
The 2012 strategy ‘Together for Mental Health: A Strategy for Mental Health and Wellbeing in Wales’ (Welsh Government, 2012), was critiqued using Bullock's et al (2001) framework. The strategy underpins the Mental Health (Wales) Measure (National Assembly for Wales, 2010) which places a legal duty on health boards and local authorities to improve mental health services. The strategy aims to deliver plans over a 10-year period and the conclusion of the appraisal gave the impression of being comprehensive and rigorous. The strategy set out a number of aims influenced by several Welsh Government and national documents referring to low and high priority levels which are to be achieved. There was a change in terminology, however, as aims were replaced with outcomes throughout the strategy document. The document also included several delivery plans over a 10-year period. It was positive to note that these subsequent plans included emerging evidence following the Adverse Childhood Experiences (ACE) study in 2015 (PHW, 2015) and in relation to the worldwide COVID-19 pandemic and its effect on the whole population (Welsh Government, 2020).
The 2012 strategy has been acknowledged as being innovative and flexible, as it was the first document in Wales to encompass all ages, bringing child, adolescent, and adult mental health into one strategy. Conversely, there was little evidence of consideration of input from service users and carers in the formation of the New Partnership Board (NPB) which had been set up to oversee the strategy. In addition, the strategy throughout referred to it being highly influenced by the United Nations Convention on the Rights of the Child (UNCRC, 1989) and the Rights of Children and Young Persons Wales Measure (NAW, 2011), yet there was a lack of young people's views during the consultation stage. Positively, however, there were significant approaches throughout which were evidence-based and although the strategy was influenced by several national and local policies working in partnership, the responsibility to implement the strategy remained primarily at local level. The strategy featured a 10-year plan incorporating three subsequent delivery plans, which contained an updated 2019–2022 delivery plan to include the COVID-19 pandemic. However, these outcomes set out within the Welsh Government strategy remained the responsibility of the public sector to achieve. The process to review and evaluate was achieved leading to the lessons learned element which was realised as part of an updated 2019–2022 delivery plan to include the COVID-19 pandemic. Unfortunately, when achieving the outcomes within this Welsh Government document, responsibility remains with public sector bodies with the NPB to oversee its implementation. Although there is some guidance on how these outcomes are to be achieved, there is little on what might be needed to take reasonable steps in meeting these, equally there is little guidance on what is acceptable if not following the recommendations within the strategy. From this strategy critique it is recommended that mental health promotion is targeted at a primary level. SCPHN school nurses have the necessary skills and knowledge to work in partnership with tier one professionals (e.g. the education sector), making them ideally placed to address this in practice (Nursing and Midwifery Council [NMC], 2015).
Literature review
A literature review was performed in a systematic approach to ensure that all available information was incorporated to answer the research question: Is mental health and emotional wellbeing promotion in schools effective in improving children and young people's emotional wellbeing and mental health knowledge as well as reducing stigma? Inclusion and exclusion criteria were applied. Exclusion criteria included research published prior to 2009 and non-English language. To choose the articles relevant for review, a computerised database search strategy was conducted and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct and Medline databases were scrutinised using various key words including: children, adolescents, youth, teenager, emotional health, wellbeing, mental health, school nurse, school nursing, school health nurse, mental health promotion in schools. From the initial search there appeared to be very little research available on school nurse-led interventions, therefore a further search to include school-led studies was performed sourcing 79 articles. These results were reduced further by applying additional criteria, resulting in 37 articles. The abstracts of these were analysed and more articles were excluded since a number of the studies appeared in lesser-known journals, indicating a small impact factor, and a number of articles were discounted due to not being relevant. The remaining six articles were further critically appraised using the Critical Appraisal Skills Programme (CASP) checklists, these were chosen to ensure a systematic approach allowing for rigorous and comprehensive analysis of the studies chosen (Aveyard, 2019).
The literature review focussed on the secondary school age group. It was evident that following school-based mental health promotion, the intervention had a positive impact on children and young people's emotional wellbeing (Kidger et al, 2009; Skre et al, 2013; Gigantesco et al, 2015; Chisholm et al, 2016; Milin et al, 2016; Bjornsen et al, 2018). Conversely, it also highlighted the lack of research available on mental health promotion led by school nurses. While the appraisal included school-led reviews, the wider evidence indicated that school staff felt they may not be the most appropriate professionals to deliver this health promotion due to a lack of confidence, training and appropriate skills.
Emotional health and wellbeing a whole-school approach in collaboration with school nurses
Although the school nursing service in Wales has identified EHWB as one of its top priorities, practice across Wales is varied in quality, methodology and the use of the service (Hayter et al, 2012). Following recommendations from the Donaldson report (Donaldson, 2015), many schools across Wales have incorporated EHWB into their day-to-day activities. Subsequently, the Welsh Government has published guidance recognising that a whole-school approach to promote EHWB of children and young people is more effective (Welsh Government, 2021). This documentis aimed at developing and sustaining healthy relationships and building resilience through a whole-school approach. It acknowledges that good wellbeing should be present not only in teaching but in those aspects of everyday life such as developing and improving problem solving skills, accepting mistakes and learning from them, understanding emotions by labelling feelings and being able to show gratitude and kindness. By developing these skills early on in primary school, children and young people will foster improved resilience which will help when they encounter challenges as they move through the different stages of their life and hopefully become equipped to deal with distress caused by poor mental health. Additionally, this ethos in schools destigmatises mental health, since labelling and talking about emotions and feelings earlier in life decreases the likelihood of mental health being a taboo subject (Carroll, 2018; Bulander et al, 2014). When a child or young person has good EHWB, they are more likely to flourish and succeed and are able to develop the coping skills that underpin resilience (McArdle et al, 2013). A mentally healthy school sees positive EHWB as fundamental to its values, mission, and culture (Allen et al, 2017). EHWB has been prioritised within The School Nursing Framework agenda (Welsh Government, 2017), therefore in their role as public health practitioners (NMC, 2004; 2018), SCPHN school nurses should be contributing to mental health promotion in schools (Weare and Nind, 2011). Coincidentally, the Welsh Government (2021) document acknowledges that schools alone cannot meet all of the EHWB needs of children and young people as these will change and develop over time. Furthermore, it is understood that all EHWB promotion should be delivered to children and young people in a timely manner to contribute and sustain progress for healthy development (Pryjmachuk, 2012). The issues raised by Pryjmachuk in 2012 remain current today and even more so since the COVID-19 pandemic.
Discussion
The School Nursing Framework (Welsh Government, 2017) more recently prioritised EHWB within its agenda, being underpinned by the Wellbeing of Future Generations (Wales) Act (National Assembly Wales, 2015) and subsequent Welsh Adverse Childhood Experiences (ACE) study (PHW, 2015). Interestingly, children's EHWB has been one of the top priorities in the past 20 years, since the introduction of ‘Everybody's business’ strategy in 2001 (NAW, 2001), which identified early on that children and young people with poor mental health are of deeper concern: not only can it adversely impact those affected, but it can destroy the quality of life of those around them (Kenny et al, 2014). Furthermore, links between poor mental health in childhood and prevalence of adult mental health problems later in life (Eruyar et al, 2018) are recognised and established. children and young people identified as having mental health difficulties at a young age and who never had access to timely support or intervention may go on to have poor mental health into adulthood. These difficulties develop over the years, without being addressed until adulthood. Thus, earlier EHWB promotion or initiatives are crucial to develop a child or young person's resilience.
The Welsh Adverse Childhood Experiences (ACE) Study in 2015 (PHW, 2015) recognises that a person who has been exposed to adversities during childhood is more likely to adopt maladaptive coping strategies and behaviours such as substance misuse, self-harm and risk taking during adolescence. These early childhood problems can lead to further mental health problems in adult life (Hughes et al, 2017; Guyon-Harris, 2020). Even though these topics are discussed as part of health promotion in schools, it could be suggested that poor mental health and poor decision-making skills underpin these risky behaviours (Compton and Shim, 2015). This would indicate that the overall focus should be on EHWB promotion. Widom (2017) implies that people who experience adversities in childhood are more likely to perform poorly at school and become involved in crime. There is also evidence to suggest that people who have experienced adversities in childhood develop lifelong medical and psychological problems impairing their cognitive and physical functioning, due to changes in brain development as a reult of these life experiences (Dye, 2018). For that reason, recognition of protective factors early in a child's life with early intervention such as EHWB promotion is seen as being key to increase a child's resilience (Dye, 2018). It could be argued that earlier EHWB promotion not only leads to improved resilience but reduces distress in adolescence and, more importantly, acts as a protective factor against anxiety and depression later in life (Gigantesco, 2015). EHWB promotion provides an opportunity for children and young people to develop the necessary skills that will assist them later into adulthood (Chodkiewicz and Boyle, 2017). Likewise, the literature review supported the evidence that mental health promotion taught as part of the curriculum or as an individual session improved the EHWB of children and young people (Bjornsen et al, 2018; Chisholm et al, 2016; Gigantesco et al, 2015; Kidger et al, 2009; Milin et al, 2016; Skre et al, 2013). These improvements can also directly affect the wider communities positively (Banerjee et al, 2016). The chosen studies were evaluated shortly after completion, nevertheless there is emerging evidence of positive long-term outcomes and although these effects will decrease over time, they will still remain significant (Dolan et al, 2012). It was established from the review that schools are best placed to undertake health promotion, due to their niche environment, reaching the specific target audience (Onnela et al, 2014). However, it should be acknowledged that even though schools are best placed, Limber and Kowalski (2020) imply that schools can also have a detrimental effect on children and young people's EHWB if they have been exposed to negative experiences while at school (Kidger et al, 2009).
Recommendations for school nursing practice
There has been little across the UK in terms of population-based health promotion provided by the school nursing service and evidence from the review implied that there were inconsistencies as to who is best placed to provide this health promotion. It could be argued that because schools are the best environment, school staff members are also best placed to undertake such interventions (Membride, 2016). However, school staff feel they are not equipped to carry out this task due to a lack of skills, training, and confidence (Whitley et al, 2013). School nurses often feel the same due to a lack of EHWB training, resources, and time constraints (Pryjmachuk et al, 2012), subsequently, they will only provide this resource if they are confident to do so. Anecdotally, SCPHN school nurses appear to be under the impression that EHWB is largely serviced by experts or need a level of expertise they do not possess and often feel that it is not within their scope of practice. On the contrary, every registered nurse should possess the core fundamental communication skills to be able to actively listen, since communication is key to any nursing activity (NMC, 2018). Good active listening skills are paramount to providing children and young people the validation they need when they need it, which is fundamental in improving EHWB. Hence, standardised practice of EHWB promotion initiatives needs to be implemented across the service alongside specific training for school nurses to enable them to work in partnership with education professionals to promote the EHWB of children and young people. This would ensure that they all have the same level of confidence in addressing these issues. For this to be possible, additional measures would need to be put in place, including increasing the number of school nurses, providing protected time, reviewing caseloads, and reviewing and auditing practice to improve and sustain the mental health and wellbeing agenda within the school nursing framework. Thus, with these additional measures in place, school nurses will become more accessible and in a timely manner.
The school nursing service can work more creatively and use the innovative skills developed as a consequence of the COVID-19 pandemic, such as utilising video and social media platforms to develop short health promotion videos that can be shared directly with schools but also be accessible in the public domain. These short health promotion videos can aim to improve children's resilience by incorporating problem solving skills, accepting mistakes and learning from them, to understand emotions by labelling feelings and being able to show gratitude and kindness. By developing these skills early on in primary school, it will help children and young people when they encounter challenges as they move through the different stages of their life and hopefully, they will become better equipped to deal with distress caused by poor mental health.
School nurses also need to be more visible in schools, whether via video or face-to-face at school events such as the transition from nursery to reception and again during the transtion from year 6 to secondary school. Supporting our education colleagues to manage young peoples' mental health and wellbeing, either through a consultative role or as part of an intervention.
Conclusions
Poor mental health is a national priority and school nurses are in a key position to support children and young people with their EHWB and provide early interventions, either directly as part of an EHWB promotion or in collaboration with education colleagues. It is important that this is based on up-to-date evidence. While the literature review highlighted that mental health promotion in schools positively improves the EHWB of children and young people, there was little evidence on school nurse-led mental health promotion taking place within schools. Therefore, further school nursing research is needed in this area. The policy appraisal also emphasised the need for earlier interventions, which are more likely to achieve better long-term outcomes. Providing an evidence-based EHWB intervention aimed at improving resilience in primary school-aged children will not merely equip children for any perceived challenges that occur through childhood to adolescence and into adulthood, but also has the potential to reduce the percentage of adults who struggle with poor mental health in the long term. Coincidentally, this also reduces the stigma attached: if an EHWB intervention is provided earlier, it encourages children to speak openly about their feelings and emotions, thus having a positive outcome on reducing the stigma and prejudice surrounding mental health. This EHWB promotion aims to complement the current teacher-led wellbeing strategies already embedded into education practice (Waters, 2011), particularly as health promotion is part of the SCPHN school nursing role (Allen, 2011) and nurses therefore play a pivotal part in providing EHWB promotion in schools. While school nurses have an abundance of specialist skills, including good communication and listening skills, the service itself is understaffed. For existing school nurses to effectively undertake EHWB promotion in schools, they would require specialist training to increase their knowledge around mental health, enabling them to feel confident to provide EHWB interventions to children and young people, but also to support education colleagues.
KEY POINTS
- Resilience improves children and young people's emotional health and wellbeing
- The specialist community public health nurse (school nurse) can be pivotal in providing emotional health and wellbeing promotion in schools
- Schools are the best setting to promote emotional health and wellbeing education