Following the recent suicides of two teenagers as a result of cyber bullying, it is clear that mental illness is becoming more prominent in young people than ever before.
The constant pressures of education, job prospects and peer pressure surrounding young people means that there are more cases of mental health problems in the young now, than there were 30 years ago.1 In addition, the increased use of social media has meant that not only are young people less likely to speak face-to-face, the risk of cyber bullying can have a detrimental impact on a young person's thoughts.
The most common forms of mental illnesses in young people are depression, self-harm, generalised anxiety disorder, post-traumatic stress disorder and eating disorders. These can affect children as young as 10 years old.1
School nurses are very often the first point of contact for a young person when they are experiencing emotional or psychological problems and so they see the impact of these figures daily.
'Around 75 per cent of the students who drop in to see me come for mental health problems and I am starting to see primary aged children also reporting emotional problems,' said Richard Cotton, a school nurse from Tunstall in Stoke-on-Trent. Figures indicate that there are just not enough school nurses to be able to combat this rapidly growing problem.
There are around 1,500 qualified school nurses in England supported by the same number of community staff nurses and some healthcare assistants. However, there are 8.2 million school-aged children in England in roughly 3,250 secondary schools, 16,884 primary schools as well as nearly 1,000 specialist schools and 400 pupil referral units.2
In 2009, the Welsh Assembly committed to providing one school nurse per secondary school. There were around 220 whole time equivalent school nurses in the country as of 2012.3 There are 280 whole time equivalent school time nurses in Scotland.4 The government's Getting it Right for Every Child campaign has no direct commitment to increasing numbers of school nurses but aims for every child under 18 to have a 'named person' which is usually a health visitor or a teacher. In Northern Ireland there were 90 whole time equivalent school nurses as of March 2012.5
The More School Nurses for Better Child Health Campaign run by the British Journal of School Nursing is working towards increasing the numbers of qualified school nurses in the UK. It also aims to improve the public understanding of the role of the school nurse, to encourage research into the long-term health benefits of having a school nurse and to ensure training and CPD.
The Community Practitioners and Health Visitors Association (CPHVA) has also started a campaign called Unite 121 to ensure that there is one full-time public health qualified school nurse for every secondary school and its cluster of primary schools with additional support from other qualified school nurses or community staff nurse if required.
Councils are beginning to invest more money in increasing school nurse numbers such as Cumbria County Council. It has just invested £85,000, for three more school nurses to be recruited by Cumbria Partnership NHS Foundation Trust.
Mental health charities are also working with schools to educate young people about mental illness. MindFull, a charity for young people with mental health problems, is calling for mental health to become a core theme in the curriculum and is planning to work with schools and school nurses to help young people learn how to cope with mental health issues. The charity will also call on schools to provide access to counselling and mentor support for young people.
Qualified school nurses are nurses that have undertaken an extra year at university to achieve a School Nursing/Specialist Community Public Health Nurse qualification. Currently the curriculum for nursing training does not have any basic requirements for mental health training.
Mr Cotton said that when he studied to become a school nurse in 2006, mental health did not form a large part of his degree. 'There may have been one or two modules on mental health but I don't think there was anything specific. Given that it is now such a major part of adolescence, it should be included more.'
However, a few universities such as Buckinghamshire New University do tackle mental health, albeit under the umbrella of emotional problems.
Jane Wright, senior lecturer in school nursing at Buckinghamshire New University, said: 'Emotional and health wellbeing are embedded in most of our modules and there is a certain amount of emotional focus in the course. However, practice is so varied across the country due to less commissioning for mental health and more for things like immunisations. There is a reasonable amount of training across practices though.'
School nurses have the option to undertake one-or-two-day courses run by the Child and Adolescent Mental Health Services (CAMHS), an NHS service dedicated to dealing with mental health problems in young people. These courses are aimed at the school nurses who want to learn something more specific regarding mental health.
'It is so important for school nurses to be trained in recognising symptoms of mental health, as they are usually the first port of call to discuss issues that young people may be having. It is also important for teachers to have that support, as they are not specifically trained to deal with mental health problems,' said Fiona Smith, the advisor in children and young people's nursing from the RCN.
There are five levels of mental health diagnosis where diagnosis at level five results in a young person being admitted as an inpatient. School nurses are trained to deal with level one issues, which covers universal problems that require a little extra support but can be solved in a short space of time. Any young person that has problems that can be classified as beyond a level one problem is then referred to the CAMHS. However, referral times are varied and may mean that problems are not addressed as quickly as they need to be.
In primary schools, nurses often hold clinics to deal with common issues such as bed-wetting, which are just as likely to stem from emotional problems as physical ones. School nurses will let parents know that these services are available and invite them to come along to talk about the problems.
In secondary schools, where a full-time school nurse is available, most of them will run drop-in clinics, where students can self-refer if they feel they need to talk to someone. The aim of these clinics is to allow the student to start those difficult conversations about how they are feeling and to understand what they are going through.
Rosalind Godson, the professional officer for school nursing at Unite, said: 'An important part of the work school nurses do sometimes have to undertake is to persuade young people to visit their GPs for further help. School nurses are in a good position to help young people find the words to describe how they are feeling.'
In the last few years there have been more and more innovative projects aimed at encouraging young people to talk more about their feelings. This is where social media can be used in a positive way.
A new web app launched on 3 September aims to help young people plan their conversations and remember their GP consultations.Doc Ready allows people to create checklists from suggested topics such as relationships, self-harm and drink and drugs or create bespoke lists to reflect their personal needs. The lists can be printed out and dated, providing records of the conversations they have with their GP.
Doc Ready has already received the backing of writer and actor Stephen Fry, a strong advocate for improving mental health services. 'The support that Doc Ready gives young people is vital to help them become the healthy and confident adults that they deserve to be. The teenage years are an important period to address mental health issues and Doc Ready is a great tool to help young people through a difficult time,' he said.
Doc Ready was created by Innovation Labs, a project run in partnership with the Paul Hamlyn Foundation, Nominet Trust and Comic Relief, and is supported by the Mental Health Foundation's Right Here initiative. The project has been working towards running a grants programme to explore how digital tools can support and improve young people's mental health.
Mr Cotton agrees that apps like this can be a useful tool. 'Voicing mental health concerns to health professionals is really stressful for young people, who commonly say that they don't feel listened to when they visit GPs etc. I think that anything that can help them structure exactly how they are feeling is of benefit, and the app at the very least demonstrates a productive use of technology which young people are fully immersed in. Apps are an excellent way of getting health messages and support to people, and I am personally all in favour of them.
'As a school nurse, I think that I would like young people to be as well prepared to discuss mental health issues with me as they would be for a GP consultation, and as we are able to refer into the same services as GPs so perhaps this could be an app that young people could use in talking to us too perhaps.'
Another project that has been trialled in various schools around the country is the facility for students to text school nurses with any health related problems or questions.
Jo France, the school nurse coordinator and clinical lead in Shropshire, introduced the scheme which ran from May to December 2012, into two secondary schools in the county. The students were engaged in the project from start to finish to produce the promotional materials. The scheme aimed to allow a young person to have more control over his or her health and remove the barrier of speaking to somebody face to face. Around 200 texts were sent during the course of the scheme.It was considered successful and both of the schools have adopted the scheme.
Ms France thought of the idea after surveys by the British Youth Council and the National Children's Bureau found that secondary school children wanted their school nurse to be visible, accessible and confidential.
Currently commissioners are reviewing the scheme with the aim of rolling it out county-wide.
Ms France said: 'The main problems that students texted in about was sexual health and emotional health. Self-harming, in particular, featured quite heavily in the texts, so it shows that the service encouraged a few students to talk about things they may not have done otherwise.'
Practice nurses and school nurses can engage with these innovations on a local level to break down barriers and ensure that all young people feel comfortable about approaching them with problems that they may be experiencing.
1. Children and Young People - Mental Health A-Z. http://bit.ly/l1m8YU
2. Unite. 121 Campaign for school nurses. 2013. http://bit.ly/15N7yqg
3. Nursing staff by area of work and year. 2012. http://bit.ly/16htBIW
4. NHS Scotland Workforce. August 2013. http://bit.ly/zZkp8C
5. Northern Ireland Health and Social Care Workforce Census. 2013. http://bit.ly/12w2SqE