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How can vulnerable young people have improved access to the School Nurses?

07 August 2019

This qualitative research by Dawn Marie Blake, explore young people’s views around accessing school nurse drop-ins.

Dawn Marie Blake Registered children's nurse with Practice Educator Qualification (PG Dip)


Author Dawn Marie Blake, a registered children's nurse with Practice Educator Qualification (PG Dip), a school nurse public health degree (SCPHN) and an MSC Award in Advancing Professional Practice and currently working as a Specialist Vulnerability Practitioner, carried out qualitative research to explore young people’s views around accessing school nurse drop-ins.


 

Research summary 

  • The aim of this study was to gain an understanding of young people’s views and perceptions with regards to improving access for vulnerable young people to school nurses via the school nurse drop-in.
  • Twelve pupils from Years 10 to 12, ranging in age from 15 to 17, took part in the study. Nine were male, three female. Two were black British, 10 were of white British in ethnicity.
  • The pupils were from the same school, and either current or former members of the student council.  A semi-structured interview was used within the focus group.
  • A topic guide included questions and prompts pertaining to the school nurse drop-in, child protection, the role of school nurses, potential obstacles to vulnerable young people accessing the drop-in and ways to overcome these obstacles to allow their health needs to be addressed by the school nurse.
  • An audio recording was used to support a thematic analysis and transcription.
  • Participants were then invited to confirm the findings. In all, the researcher visited the focus group three times during the study, for up to 60 minutes each visit.
  • Responses were collated into themes or groups of concepts with similar characteristics. The dimensions of these categories were then identified and linked to sub-categories (Charmaz, 2000) to aid analysis.

Introduction


School nurses have an important public health leadership role in schools and the wider community. This includes contributing to health need assessments and designing services to reach young people, wherever they are in the community environment (Department of Health [DoH] 2009; 2011; 2012; Public Health England [PHE], 2015) This paper highlights the importance of the school nurse’s role in providing support to vulnerable young people. Evidence is provided from review of a study which captures a group of young people’s voices in relation to improving access for vulnerable young people to the school nurse.


Throughout the UK the School Nursing Service is a relatively small resource (DoH 2009; PHE 2015; 2016; Schuller &Thacker, 2015; Summach 2011). However, despite this, prior to 2016, school nurses in a small team in a moderate sized city in England committed to provide a weekly confidential drop-in service for young people in secondary schools. At this, the school nurse would assess the health needs of the young person and offer support to address these needs, which could range from sexual health, relationship advice and support, emotional health support, smoking, drugs and alcohol advice, puberty support, healthy eating and exercise advice.


What was interesting is that this service was one of the final services on offer, as the drop-in service offered by the school nurses had been suspended in two areas of the city due to dwindling numbers of young people accessing this service. It was believed that this was due to accessibility and flexibility of the drop-in services, due to the cost implications that brings at a time of lack of resource and investment for the service in the area where the study was conducted. However, for the team in the study area it was felt that every effort to improve access should be the focus and a priority within the service, due to the overall benefits that the team thought the young people gained from it. As the team knew, to provide young people with a service they want, interventions need to be offered to young people that are accessible and user friendly (British Youth Council, 2013; DoH, 2012).


As literature suggests, School Nursing Services need to explore and evidence more creative, innovative and smarter ways of accessing young people that are cost effective. School nurses in their public health role are well equipped to identify and implement change that can lead to better outcomes (DoH, 2009; 2011; 2012; PHE, 2015; 2016). Using resources effectively and providing a more tailored service to meet the needs of young people is highlighted within the Call for Action (DoH, 2012). The RCN (2017) highlights that school nurses deliver universal and targeted services working across education and health, providing the link between school, home and community. They are responsible for delivering programs to improve outcomes for school age children and young people aged 5-19. This includes reducing childhood obesity, reducing under age conception rates, the prevalence of chlamydia, school entry screening, immunisations and supporting mental health and resilience (DoH, 2009; RCN 2017)


School nurses need to offer choices in terms of access to young people to ensure that services are accessible, confidential and are what the young people actually want, taking into consideration their views on times and location. Young people want to be able to offer their views about the services they receive (National Children’s Bureau [NCB], 2013; British Youth Council, 2013; 2013; DoH, 2012; Wainwright et al, 2000). 


France (2014) stresses that, although young people find school nurses approachable and caring, too few access the service. It can therefore be argued that improving access for young people to the school nursing service is a wider concern 


Certain groups of children and young people, such as looked after children, children and young people with complex or enhanced health needs, children and young people whose family background puts them at higher risk, have particular vulnerabilities and susceptibility to poor outcomes (DoH, 2009; DFE 2018; NSPCC, 2013). Vulnerable children and young people are those disadvantaged children and young people who would benefit from extra help from public health agencies in order to make the best of their life chances (DoH, 2002; DFES, 2004; DFE, 2018; Wulczyn, 2010). Every Child Matters Change for Children (2004) identified a nationaframework to build services around the needs of children and young people. Improving the quality and reach of existing services and health promotion settings are necessary precursors to improving health and wellbeing of children and young people (DoH, 2007; 2012; PHE, 2015).


Improving access to vulnerable young people via the 0-19 health visiting/school nursing service will enable school nurses to undertake an holistic assessment, address any health needs identified and offer a package of care; this provided rationale and justification for completing this study.


The focus of this paper is to share the findings of a research study which explored young people’s views in relation to accessing school nurse drop-ins. The paper will do this by providing background to the lack of information surrounding this area of practice.



Background 


School nurses and their teams work and collaborate with other professionals to ensure there is seamless support to children young people and their families delivering the Healthy Child programme (DoH 2009; PHE 2015). France (2014) argues that regular reliable drop-in clinic provides one of the most suitable routes for young people to access the school nurse.


From the researchers’ experience, the schools would initially support the introduction and promotion of the drop-in service, promoting the service in form tutorials and assemblies. However, the support from school would appear not to be sustained after a few weeks. School nurses would often report that the rooms provided by the schools for the drop-in would often be changed at the last minute, which would mean young people would not know where the school nurses were located. School would regularly have meetings in the room which had been provided for the school nurses for drop-in, or school meetings would be double booked or over run in the room allocated for the drop-in, which would mean the school nurses would have to find an alternative room to use, again meaning the young people were unaware where the school nurse had moved to, or were given the impression that the school nurse had not arrived or that drop-in was cancelled. On few occasions an alternative room could not be provided from the school, which meant drop-in would be cancelled on the day, which could have an impact on any young person wanting to access support that day, delay in identifying and addressing health needs and time wasted for the school nurse, or the support offered by school nurses deemed unreliable. 


The British Youth Council (2013) emphasises young people should be told where school nurses can be found and know when they are available to see them. Increasing visibility of school nurses is what young people want, as highlighted by the DoH (2009; 2012) and British Youth Council (2013). This was identified by collating young people’s views on the role of the school nurse via a survey undertaken by the British Youth Council.


Munro (2011) stresses early identification of childhood issues and service provision is in the child’s best interest. All those who in come in contact with families have a part to play in identifying those children whose needs are not being met by universal services.


The school nurses undertake a yearly health review, which is statutory for looked-after children, where they see young people face-to-face. However, the main access to young people would be via the drop-in to address health needs and, as highlighted, this has its challenges.


The researcher adopted a qualitative approach to undertake the study as it felt pertinent to capture the voice of the young people particularly as the overall outcome is to develop a service around the needs of the young people. Adopting a qualitative approach allowed the researcher to gather first-hand views of the young people which were meaningful. This study gives a better understanding of vulnerable young people’s views and perceptions with regards to improving access to the school nursing service via a drop-in. Where quantitative studies can often be biased by preliminary conceptualisation, this qualitative study provides a much wider picture because the young people themselves came up with the relevant themes in relation to their thoughts, opinions and past experiences.



Methodology Research Design


Research Questions and aims


The aim of this study is to gain an understanding of young people’s views and perceptions with regards to improving access for vulnerable young people to the school nurses via the school nurse drop-in.


The question, which has developed from the outset and remained the focus of this service development, is ‘How can vulnerable young people have improved access to the School Nurses?’


To gain a holistic understanding of the young people’s views and perceptions a semi structured interview with the young people was employed to use within the focus group. Details of the participants within the focus group can be seen in Table 1.

Number of participants

12

 Age range

Year 10 (eight 15-16 years old)  Year 12 (four 16-17 years old) This age group was recruited due to recommendation from the schools Head teacher to utilise the young people within the school council

 

 Contact with school nurse

One male and one female voiced they knew friends that had contact with the school nurse. One young person voiced he had seen the school nurse at his previous school.

 Gender

Nine male, three female

 Ethnicity

Two black British, 10 white British

 

Table 1 - Details of the Participants

 

The topic guide included questions and prompts pertaining to the school nurse drop in, child protection, role of the school nurses, potential obstacles in vulnerable young people accessing the drop-in and ways to overcome these obstacles to allow their health needs to be addressed by the school nurse. It was felt that by including these questions it would facilitate depth and clarification, and identify any strengths and difficulties that vulnerable young people face when accessing services.


The Head teacher and the support team agreed that the school council could be used for the focus group and agreed to the study. The Head teacher felt that the school council was committed to the school and had an interest in young people’s welfare. The young people from the school’s council were approached in April 2017 with the aim of starting the focus group from May 2017. The study did not commence until approval was gained from the local Children’s Trust and university ethics committee.


Twelve young people from a secondary school within the centre of the city participated in the focus group. These volunteered out of a possible sixteen. All sixteen school council members were given information about the study and were given a choice to be included in the study. Most of the young people who participated in the focus group were from the school council - nine in total, and three who had recently left the school council but still wished to be included in the study. 


A thematic analysis and transcription was then undertaken by the researcher. The initial data was analysed by the researcher and confirmed once the researcher had revisited the members of the focus group. This provided opportunity for the participants to confirm the findings. Lincoln and Guba (1985) and Polit and Hungler (1999) emphasise that member checking is considered to be a valuable strategy for establishing the credibility of qualitative data. The audio recordings proved a valuable tool due to the researcher working alone on the study. Each young person within the focus group selected a number from 1-20 at the start of the discussion which they would use prior to offering their views which were recorded. The semi structured questions encouraged open-ended responses from the participants, enhancing discussion. More than one visit to the focus group was factored into the study as the themes emerged. The researcher visited the focus group three times in total. Each visit lasted between 50 and 60 minutes.


The data from the focus group was repeatedly listened to and reviewed by the researcher. This was to ensure that the formulated meaning truly reflected the intent of the participants. Each response from the young people within the focus group was given a code and collapsed into themes or groups of concepts with similar characteristics. The process of coding and categorising continued until no additional information was revealed through data collection and categories were rich and complete (Strauss and Corbin 1990).


The dimensions of these categories were then identified and linked to sub categories (Charmaz, 2000), which made it easier for the researcher to analyse, as can be seen in Table 2

 

Main Theme

 Subtheme        

Barriers to vulnerable young people’s access to drop-in

  1. Young people’s attitudes, non-confidential service, embarrassing, seeing exams more important, not private, location young people lack confidence, unfamiliar face, non-trustworthy, seek support from GP, afraid of what peers may say, relationship between young people and school nurse, unfamiliar with service

1.2 School staff attitudes -lack of understanding.

Role of the school nurse

2.1 young people lack understanding of the school nurse role

2.2 school staff unaware of school nurse’s role

Facilitators to vulnerable young people on child protection plans, Team around the family meeting school nurse face to face

3.1 Relationship with school nurse, Recognition of what support can be offered to young people by the school nurse

 1-1 confidence for them being in the meetings.

 Invitation to drop-in

3.2 Location

3.3Flexibility of drop-in

3.4 School nurse partnership with school staff and young people

3.5 Promotion of drop-in

 

Table 2 - Data Analysis Using the Framework Approach (Pope et al 2000, Richie et al 2003) highlighting the Main Themes and Subthemes Emerging from Data
 


 

Findings and Results


Barriers to vulnerable young people’s access to drop-in


Most of the participants within the focus group expressed that they had not used the school nurse’s drop-in or had contact with the school nurse before. 


Participant 1


“Drop-in should be easy to access but not visible.”


“I’ve never used the drop-in… There are young people with mental health problems …. We don’t know that school nurses can help… drop-in needs to be regular.”


Role of the School Nurse


France (2014) identified young people expressing the need for high quality personally relevant information, accessing this information from qualified health individuals within a comfortable, trusting respectful relationship. Students within this study expressed the need for privacy. The results of Sherwin’s 2019 study identified the importance of providing regular support and building trusting relationships. These themes became apparent within this study.


Participant 3


“I would have gone to the school nurse had I known they could support me.”


Participant 2


“I know they do lots of things but we have never actually been told what you do.” 


“If I trusted the school nurse maybe I would feel more confident.”


Participant 7


“I‘ve had basic info and I’m not sure if others have just had basic information too; some people I think don’t fully understand the role. They may have an idea but not know what is available.”


Facilitators to vulnerable young people – those on child protection plans, or subject to team around the family meeting.
The participants expressed that vulnerable young people who are on child protection plans, involved in Child in Need meetings or children in care need to be invited discretely to the school nurse drop-in. The participants recognised the school nurse as a professional external from the school, who could offer emotional support, support to address any risk taking behaviours or support in relation to their presenting health issues particularly if it was a serious problem. They recognised the impact that this could have on a young person 


Participant 11 


“I think it is really important as it is about them and they need to have their say. Invite them to the Drop in. The school nurse may know how to help that young person in different ways from teachers, school social worker or their parents.”


Participant 4


“This means it is serious, the school nurse needs to meet with that young person face to face so they can understand what the young people needs and listen to them. It would be difficult to support the young person if you have never met them before… I agree invite them to Drop in” 


Etheridge (2004) found that school staff were often uncertain of what school nurses do or should do. It could also explain why some young people felt it was the responsibility of the school nurses to educate young people and school staff about their roles.


Participant 7


“School nurses need to get more involved in the school … to be visible... they could do this by joining in activities with school staff, working in partnership with the school doing assemblies. Form time…this way we would know what school nurses do.”


The participants expressed that the drop-in should be delivered between one and three times a week, dependent upon the size of the school. Time of the drop-ins should be more flexible to include weekends in a location that was known to the young people.


The participants also expressed the need for the school nurse to be accessible in school when the young person needs them.


Participant 12


“Drop-in needs to be in school time during lessons so you can go when you need to see the school nurses and not wait.”


Participant 3


“I think school nurses should be more flexible so young people can see them when they need to at different times even outside of school….maybe in a GP surgery “



Discussion 


In practice, school nurses would therefore need to ensure that the same school nurse sees the individual young person to build a rapport and develop a therapeutic relationship and trust. Allowing young people to be involved with designing the drop-in posters is what the young people suggested could improve relationships between the school nurses and schools, while improving access to the drop-in clinics would allow the young people would become more familiar with the school nurses, while developing trusting working relationships and breaking down any barriers and stigmas. 


Summach (2011) highlights that nurses who strive to develop trust in young people will maximise adolescent health results. Fewings (2016) argues negative feedback or dismissive feedback will influence other young people which in turn results in them not seeking support or accessing a service.


One concerning view raised by one participant in the focus group was the lack of trust he had for the school nurses. Leavey et al (2011) reports fear about lack of confidentiality is a major reason for young people’s reluctance to seek help. 


Reeves et al (2009) and Shone (2010) highlight young males do not often access services in their own right.
The majority of the participants within the focus group were young males who were willing to express their needs and have their views heard, which was most pleasing to see as they are often the minority to access the Drop-in service.
Greenwood and Smith (2015) highlight that insufficient service information was frequently emphasised as a barrier for males accessing support.


Access to school health clinics have been linked with improved student achievement and health (Harper et al, 2016). The drop-in service can provide the ideal opportunity to assess the needs of vulnerable young people and can be the ideal forum to provide young people with packages of care to address any health needs identified, with the aim of improving outcomes for the young people attending the drop-in service. 


The participants expressed that school nurses should make themselves more visible in school; this would allow young people and school staff to gain a greater understanding of their role as well as improving access.


Etheridge (2004) found that school staff was often uncertain of what school nurses do or should do. The school nurses participating in school assemblies and form time as suggested by one young person could enhance greater understanding of the school nurse role and what school nurses can offer. 


Location of the school nurse drop-in is essential as a high representation from the focus group voiced concern with regards to the room not being in a potentially stigmatising area of the school. 


School nurses are skilled practitioners able to identify signs of neglect and respond appropriately offering support (DoH, 2009; DFE, 2018).


Brigid Daniel (2010) emphasises that the recognition of neglect is inconsistent and referrals to services are often triggered by other events or concerns about vulnerable children. Children do not gain access to universal services, therefore health and education professionals play a crucial role in recognising and responding to signs indicative of neglect.


Children who are neglected are unlikely to express the need to seek help directly from agencies and their parents are often ill equipped to seek and make use of support services (Connell-Carrick and Scannapieco, 2005; Carter and Myers, 2007; Daniel 2010; 2015).


Vulnerable children and young people should be a key focus of healthcare interventions if inequalities are to be addressed (Joshua et al 2015). 


Schuller and Thacker (2015) emphasise that young people and children need ease of access to their school nurse. France (2014) stresses although young people find school nurses approachable and caring, too few access their service.


School nurses need to be creative in how they can gain wider access to vulnerable young people, targeting a tailored, centred approach delivering packages of care could be seen as a way forward.


There were mixed feelings from the focus group with regards to how they perceived vulnerable young people felt with regards to accessing a school nurse drop-in. 


The feelings of embarrassment appeared to be prevalent during the discussions in the focus group. However, enabling the young people to understand the role of the school nurse was seen as a facilitator to breaking down this barrier

In 2017 the school nurses offered a monthly health clinic for young people, which was contrary to the findings of this study. The young people within the study openly voiced a drop-in service should be regular, at least three times a week and covering the weekend, dependent upon the size of the school and the number of students. They expressed the need for invitations for the most vulnerable young people. Alternative venues and location need to be acknowledged, as well as school nurses raising their profiles to allow teachers and young people to have an awareness of the role. This is recommended from the results of the study and if the requests of the young people were to be implemented this would have implications on the current school nurse resource allocation and future investment would be required.


School nurses would need to strengthen networks and communication across agencies to ensure cost effective facilitates can be provided and sustained.


Admin support would need extremely beneficial to undertake future research. Investment into tools which support the analysis would also be beneficial, cost-effective and less time consuming. Training may also be required to enable the researcher to use such tools. However, the cost needs to be balanced with the need for school nurses to undertake further research to inform evidence-based practice in order to move the service forward.


Whittaker et al (2012) argue one of the difficulties in establishing any group, is getting a group to attend and engage. They gave up their lunchtime to participate in the study, which was encouraging and positive.


As the school nursing service moves towards the implementation of 0-19 Health Visiting and School Nursing service redesign, which incorporates workforce planning, costings, the design of care pathways, training, and implementation of the packages of care, there is the need to research the needs of older young people, aged up to 19 years. These young people may not be attending educational establishments, or could be attending educational establishments elsewhere, such as colleges. This study was limited to years 10-12 and did not include contextual factors. There is also a lack of evidence pertaining to the younger age group, which needs to be considered for further research. Wainwright et al (2001) stress that the extent of clinical research relevant to school nursing remains limited, which provided further justification and rationale to undertake this study.


As services evolve, the need to stay focussed on service users’ needs is crucial, whilst trying to be realistic around cost efficiency. Continuing to be creative and innovative will ensure that the service continues to meet the needs of the most vulnerable young people, whilst working on cost efficiency plans. As the researcher’s role as Vulnerabilities Specialist Practitioner evolves, it is evident that the role is to supervise school nurses and health visiting, as well as creating packages of care, and training the nurses to deliver the packages of care.


This study provides the evidence and starting point to offer packages of care to this vulnerable population via school nurse drop-in using a targeted approach. 


This study highlights the need for school nurses to raise their profiles within school, and be more flexible to address the vulnerable young people’s needs. The study has highlighted the need for school nurses to work more closely with schools, establishing networks with the school. 


The participants expressed the value of face-to-face contact with the school nurses, and expressed the seriousness of this, particularly for vulnerable young people on child protection plans, those involved in ‘child in need’ meetings or ‘team around the family’ meetings and looked after children.


Although the school enrols students city wide and from out of city, the qualitative study involved a limited number of young people. It is, therefore, difficult to generalise findings outside of local context, although there will be similarities to other areas of the UK.


The backgrounds of the young people who participated in the focus group were also unknown, so it is unclear if the voices of children on child protection plans were represented. The school was newly developed only having year 10-12 pupils on role, therefore the views of young people outside of the age range were excluded from this study. The study was limited to young people attending school. 


The study did not include young people who attend pupil referral units (young people who have been excluded from mainstream school) or those attending EBD school (emotional behavioural difficulties) where engagement with these cohorts appears to be challenging. These young people are considered to be vulnerable. Furthermore, other contextual factors may have been evident, had the study been undertaken in other areas where certain ethnic and racial cultures are predominately represented. 


Consequently, it is difficult to generalise the results of this study to all vulnerable young people in secondary schools.
This study focused on the perspectives of young people the majority being male attending school. Further research is therefore required to explore the views of younger people of secondary age capturing equal representation from both genders and those who do not attend school, who are deemed to be the most vulnerable and often referred to as the ‘hidden children’. More of these vulnerable young people are now being identified and on child protection plans. More research is required. The knowledge base pertaining to this cohort needs to be increased to allow the school nursing service to align to the needs of this population. As one of the participants with the focus group suggested, school nurses facilitating drop-ins in GP practices could be the start of future developments. 


Lack of financial opportunity should not stop school nurses from being more creative and looking at how services may be delivered more efficiently. The RCN (2018) stresses a lack of investment in school nursing services risks harming children’s health and has called for urgent action to address an ongoing decline in these specialist early intervention roles
However, if school nurses are expected to work weekends at the request of the young people this will have cost implications on the service. With the implementation of the 0-19 service redesign, school nurses need to think outside traditional delivery models and utilise expert skills, listening to the voice of young people to transform services. There needs to be acknowledgement of the support, investment and training which would be required to implement these changes. McClusky et al (2018) stress that school nurses need to thoroughly describe the work they do and collaborate within the school community to advocate for increased resources. The RCN (2018) stresses that in order to service adolescents, public health nurses are dependent on collaboration with professionals in schools.


The changes recommended, identified from the study, are that school nurses need to be more flexible if they are to improve access to vulnerable young people. This includes consideration of the school nurses working in the evenings as well as weekend cover. The young people who participated in the focus group voiced that young people who were considered to be most vulnerable – those on child protection plans, those designated as a ‘child in need’ and looked after children - need to be invited to access the school nurse drop-in. School nurses need to raise their profile, visiting the schools more regularly working closely with school staff, supporting school assemblies and classroom work, which will in turn enable school staff and young people to become familiar with their role. Granrud et al (2019) emphasise that public health nurses need to make themselves and their competence visible.


Whilst some young people like the school nurse drop-in to be at school for ease of access, location and time needs to be taken into account. Alternatively, some young people stressed the need for school nurses to consider alternative venues to facilitate the drop-in service, such as GP practices. In order to address these changes greater investment into the service is required, which would mean at least doubling the size of the 5-19 school nurse team in the locality of city where this study was undertaken. This would allow a qualified nurse with two school staff nurses per secondary school. Service development and change needs to continue to ensure evidence-based practice is delivered to meet the needs of vulnerable young people in this modern, complex and changing world.



Conclusion


School nurses have a crucial role to play in improving access to vulnerable young people. The future development of this role will not occur unless the role of the school nurse is clearly defined, and understood and valued by young people. Engaging vulnerable young people is key to identifying needs as they hold the power to talk positively or negatively about the experience of a service.


To ensure that the voice of young people continues to shape best practice in tune with their needs is essential for future studies.


The study has highlighted that vulnerable young people will access the school nurse service if they are invited to drop-in and the school nurse is familiar to them, but more work needs to been done to allow the young people to be aware of their role. Drop-ins need to be flexible to meet the needs of the young people.


School nurses need to work more closely with schools and key agencies to help raise their profile.


This study will add further evidence pertaining to school nurses and can be added to the small amount that already exists. School nurses in their leadership role are required to move services forward, making services more accessible and ensuring evidence-based practice. 


This study has enriched the understanding of young people’s views and perceptions of accessing school nurse drop-ins. For the young people the key to improving access is a collaboration of the themes identified from this study, which provide the pathway to address health needs.


It must be acknowledged that in order to implement the findings from this study, future investment into school nursing would be required. 


This study was undertaken in 2017 and already positive changes are beginning to occur in the area that the study was undertaken, which includes recruitment into the service and development of packages of care which are evidence based. The 0-19 Health visiting and school nursing service has been reviewed, identifying packages of care to be offered to the most vulnerable, which includes young people on child protection plans and looked-after children, increasing access and support to this cohort of children and young people. The school nurses will now see vulnerable young people if a health need is identified that can be addressed by the school nurses via the evidence-based packages of care over a set period of time. The packages of care will be evaluated on each contact with the young person with a clear exit strategy, which is an improvement in the previous school nurse offer.



Acknowledgements


I acknowledge and give thanks to my academic supervisor for her positive encouragement, time and continuous support; the young people who participated within the focus group; the secondary school leadership team; the school nurse service manager for her support, encouragement and participation; also to my work colleagues and family for their patience and support.

 


 

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