Article
Teacher-reported prevalence and management of child health problems at primary school
Journal of Child Health Care 1–9 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493515569327 chc.sagepub.com
Anna F Leyland1, Kate E Pickett2, Sally Barber3, Rosemary McEachan3 and John Wright3 Abstract We explored primary school teacher-reported experiences, prevalence and management of child health and developmental problems and medication administration from one multi-ethnic urban community in England. A survey was delivered to 90 reception class teachers in 45 primary schools, and semi-structured interviews were conducted with a purposive sample of eight respondents. Fiftysix percent of teachers completed the questionnaire. Findings suggest that teachers and school staff may represent an underused resource for identifying children with developmental and health conditions and that the connections formed between schools and families could be utilized by other services by delivering interventions in schools where possible. Whilst most schools use a policy to inform the management of child health in school, some key areas such as training and documentation of medication administration may not be followed in practice. Interview findings supported and expanded on survey data by identifying barriers to collaboration between services and families. Keywords Child health, deprivation, medication administration, school, survey design
Introduction Health in early childhood forms a foundation for development and is an important factor for physical, intellectual and emotional well-being (Marmot, 2010). The child mortality rate in the United Kingdom is the highest in the European Union (Wang et al, 2014) and around 21% of
1
Department of Psychology, University of Sheffield, Sheffield, United Kingdom Department of Health Sciences, University of York, York, United Kingdom 3 Born in Bradford, Bradford Institute for Health Research, Bradford, United Kingdom 2
Corresponding author: Anna F Leyland, Department of Psychology, University of Sheffield, Sheffield, S10 2TN, United Kingdom. Email: [email protected]
Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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children aged between 5 and 15 years have a long-standing illness or disability (Office for National Statistics, 2013). Given the amount of time children spend in school, education settings can play a critical role in identifying and managing developmental and health problems in children. The management of child health problems in school is a collaborative effort between health and education services and families. School nurses are an example of integrated working between health and education services; however, most UK schools do not have access to a full-time school nurse service (Royal College of Nursing, 2009). A key challenge for schools is the administration of prescribed medication during school hours. It is important that schools are enabled to manage and administer medication in school safely. The publication Managing Medicines in Schools and Early Years Settings (Department for Education and Skills, 2005) aims to provide a clear framework to inform the development of policies by UK local education authorities and schools. Although most UK schools report having a policy to inform the management of health problems (e.g. Chakraborty and Hamer, 2005; McCann et al., 2002; Wong et al., 2004), research has found that medication is often administered in school by non-health professionals with little to no training (Allen et al., 2012; McCarthy et al., 2006). Evidence from the United States suggest that medication errors commonly occur in school and that some of these mistakes can have a negative impact on a child’s ability to learn or socialize and can harm their physical or mental health (Canham et al., 2007; Clay et al., 2008; McCarthy et al., 2006). Young children at school may be disproportionately affected by any errors as they may lack the skills to manage and administer their own treatments. Existing evidence highlights the importance of research in this area; however, the vast majority has originated from the United States, and there is a need for research representing countries with differing public service systems, such as those in the United Kingdom.
Objective The objective of the study is to gain an understanding of child health and development in an education environment across the following four overarching areas: (1) teacher-reported prevalence of health problems and treatments received in school, (2) medication administration in school and the policies and procedures that support the management of child health conditions, (3) teacher practices and experiences of meeting child health needs and how this fits with the wider role of a teacher and (4) systemic processes around the child that support or hinder the school staff members’ ability to manage child health needs. These overarching themes were identified by school representatives who attended a Born in Bradford cohort study consultation event. Time of school entry was also highlighted as a critical period for child health and development as school staff learn about children’s additional needs and can play a key role in identifying undiagnosed or emerging conditions. The impact of social deprivation on these overarching areas was also considered. The following research questions fit with the four overarching themes: (1) How many children do teachers report as having suspected or diagnosed health and developmental conditions and how many children receive treatments in school? (2) What policies and procedures exist to support the management of child health conditions and medication administration in school and are these policies followed in practice? (3) How do teachers feel about working to meet child health and developmental needs, delivering medications and what impact do they see this responsibility having on the classroom? (4) How does working with other systems around the child support or hinder the school staff’s ability to successfully manage child health and developmental needs? 2 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Methodology The study used a mixed-methods design where research elements were conducted sequentially (questionnaire and semi-structured interviews) with equal emphasis being placed on the findings of each method. This approach was taken to gather a systematic description of the issue under consideration. The questionnaire provided a breadth of understanding about the prevalence and management of child health conditions and identified systems supporting these processes. The interviews complemented and elaborated on the survey results by enabling exploration of teacher experiences of managing child health conditions in school. The findings from each methodology were combined at point of presentation of results to reflect the interdependent nature of the findings. Mixing results at this point offers greater profundity of the findings and overcomes the limitations of data gained from the survey by presenting alongside it the complementary findings from the interviews, and vice versa.
Development of questionnaire and interview schedule The main items of the questionnaire and interview schedule were developed interdependently following a literature review and consultation with school representatives. The literature review supported the development of the questionnaire and interview items through two means (1) topics and tools were identified that had previously been utilized and explored (e.g. medication administration by non-medically trained staff; identifying whether a policy exists to inform medication administration) and (2) identifying gaps in the existing literature (e.g. lack of description of issue from teacher perspective). Further to this, expert opinion on the items was gained through consultation with co-authors. The questionnaire was refined following a pilot with four primary school teachers and the interview schedule abbreviated and simplified following a pilot with one primary school teacher. All pilot data were excluded from further analysis. The interview schedule and questionnaire were designed to address the same four overarching research areas, namely, prevalence, medication administration, teacher experiences and systemic processes. Prevalence. Teacher-reported prevalence of child health and developmental conditions was explored with three questionnaire items regarding formally diagnosed and suspected conditions and the treatments being administered in school (e.g. ‘As far as you are aware, how many children in your class have the following health problems?’, followed by a list of 18 common condition problems, e.g. asthma). Medication administration. Six questionnaire items asked about school processes and procedures for administering and storing medications (e.g. ‘Who is responsible for the delivery of medications to your pupils?’). The interview schedule asked two complementary questions on this topic to elicit more information (e.g. ‘Where are medications and inhalers stored at school?’). Teacher practices and experiences. Three questionnaire items focused on teacher experiences and practices (e.g. ‘How confident do you feel about meeting the health needs of the children in your classroom?’) and this area was explored more fully through three interview questions (e.g. ‘Do you ever give out medications or treatments, like inhalers? If so how do you feel about doing it?’). 3 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Systemic processes. Two questionnaire items explored the concept of systemic processes (e.g. ‘If you had a concern about an ongoing health problem of a child, what would you do?’) and this was supplemented by two interview questions (e.g. ‘If a child has a suspected or diagnosed condition how do you work with families to meet the child’s needs?’).
Data collection Staff from 45 of 157 primary schools in a multi-ethnic city in the north of England were invited to participate. Questionnaires for teachers of each reception class (N ¼ 90; children aged 4–5 years) in the school were hand delivered to and collected from administrative staff. Teachers could opt in to be contacted about an interview by providing their email address at the end of the questionnaire. If teachers chose to not give contact details then participation could remain anonymous. The first eight teachers to return the questionnaire provided contact details and when contacted gave their consent to be interviewed. No further teachers were contacted. Interviews were conducted in school and lasted 20–30 minutes.
Data analysis Questionnaire data were coded, processed and analysed using Statistical Package for Social Sciences version 21.0 for Macintosh. Semi-structured qualitative interview audio recordings from eight participants were transcribed in Microsoft Word and analysed using framework analysis (Ritchie and Spencer, 1994).
Ethics The project was given ethical approval by the University of York’s Health Sciences Research Governance Committee.
Results The response rate to the questionnaire was 56% (50/90), which represented 60% of schools contacted (27/45). Findings from the questionnaire and interviews are presented together grouped into the four overarching themes of the research, namely, prevalence, medication administration, teacher experiences and systemic processes, to ensure enhanced understanding of each theme.
Prevalence of health and developmental conditions Teachers’ average reported prevalence of diagnosed and suspected health, developmental and behavioural conditions are presented in Figure 1 and specific health, developmental and behavioural conditions and special educational needs are shown in Supplement Table 1. Average suspected conditions in reception classes in each participating school (N ¼ 27) were significantly correlated with school deprivation on three indicators (Supplement Table 2). All data for this theme were gained through the questionnaire. 4 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Median children per class
14 12 10 8 6 4 2 0 Diagnosed conditions
Suspected conditions
Treatments in school
Figure 1. Median numbers of children per class reported by teachers as having a diagnosed or suspected health or developmental condition and those receiving treatments in school; error bars show 25th and 75th percentile.
Medication administration The responses to the questionnaire covering medication administration, teacher training and responding to an unmet child health need are presented in Supplement Table 3. The majority of teachers reported a school policy informing the management of health problems (96%); however, fewer reported documenting medication administration (66%). Despite the low amount of training overall, most respondents reported that they felt they did not need any more training (58%). However, the interview findings indicated that more training may occur in school than was reported in the survey. Each school will respond to the pupils that they’re getting in and because we seem to be picking up the autistic pupils I need to put the support in for staff and we’ll have the training. (Participant 5)
Teacher practices and experience of managing child health needs Overall teachers’ average rating of confidence was high for meeting the health needs of their class (M ¼ 5.6, SD ¼ 1.1; 7 ¼ most confident) and delivering medications (M ¼ 5.4, SD ¼ 1.8) as reported in the questionnaire. In interviews, teachers talked about how teaching experience, knowledge of child health and development, conducting research and targeted training had equipped them to manage child health problems and reduce the impact on the classroom. In terms of it affecting the teaching it [a child needing their nappy changed] did in a way cause you had to stop what you were doing to go manage it. But like I say they’re young it happens, we’re used to it . . . but because I’m used to it I’ll make sure that what needs to get done gets done. (Participant 4)
Teachers had a holistic view of children and so considered meeting a child’s health needs as part of their role, although they acknowledged that at times they were performing duties that extended beyond the ‘role of a teacher’ and these duties caused discomfort for some teachers and staff. You kind of feel like your role is a bit more than a teacher now because your role is that you’re a parent and a social worker and a doctor and a nurse and everything else, so it’s a lot more demanding than I think people think. (Participant 6) 5 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Questionnaire results reported health conditions as not impacting greatly on the classroom (M ¼ 4.6, SD ¼ 2.l; 7 ¼ least impact). Interview findings identified areas, such as tiredness, poor concentration, low attendance, challenging behaviours due to pain or discomfort and not being able to take part in outdoor activities, where health conditions can impact on the children at school. A girl in my class that’s got quite severe asthma and has spent [a lot of time] in hospital because of it, so she missed a lot of time from school. (Participant 4)
Systemic processes Questionnaire data indicated that more support was desired from educational psychologists, school nurses and specialist health-care practitioners. Teachers reported that in response to a perceived unmet health need they would most commonly act to access specialist advice from others teachers within school, school nurses and by liaising with families (Supplement Table 3). These reported actions were supported in interview reports. We’ll get a team involved where we’ll speak to parents, chat to the school nurse, see if there’s anything that’s come up in their history or [from] home visits. (Participant 4)
Interviews revealed that the school nurse service was viewed as being an effective means of working between health and education services and with families. However, teachers reported that it would be beneficial if health and specialist services could offer more comprehensive advice and guidance directly to schools. So we do work with the school nurse a lot in terms of dietary needs, generally because children are very underweight or very overweight. So we work with her. We currently have one example, we’re filling in a food diary and we’ve asked at home for them to do the same thing . . . . (Participant 1) We often have to chase [child health information] up, it often has to come from us to find out. If it’s kind of a smaller health issue then we have to find that out. If it’s something big then it’s usually quite good, the hospitals are quite good at sending off information about things. (Participant 1).
Teachers reported barriers in health and specialist service accessibility, particularly, with families not feeling listened to by professionals, indirect referral pathways, service responses to missed appointments, waiting lists and indirect information sharing, that is, to school via families. The importance of forming strong relationships between the school and the family was emphasized as being beneficial for child health and well-being. Effective links were often identified by frequent communication, often on the playground before or after school, and the use of diaries or notes passed in child book bags. The speech and language [therapy team] has been the hardest one to work with, if parents miss an appointment they’re dropped off the system and then trying to get them back on the system it’s a long waiting time again. (Participant 4) If you form that relationship with them [parents], I think that a lot of them do get less defensive and I do think that a lot of them do take up what you have to say and do take your advice but I think it’s gaining their trust and confidence first and especially if they’ve had a negative experience of school themselves they’re not going to come anywhere near. (Participant 4). 6 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Barriers to communication and collaboration with families included when families do not pick up their children from school, where they had untrusting feelings towards schools in general and language barriers. Barriers were overcome through home visits, the use of translators, verbal communication rather than written and employment of family liaison workers. Especially at this age, first year of school, you’ve got to get that communication there, cause you know it’s little things like, if a parent can just tell you that they haven’t slept very well or that they’re just tired, or that they have had a bad night with asthma then it just puts those pieces together in the jigsaw puzzle really. (Participant 4)
Discussion Interdepartmental collaboration for early identification of child health problems, health education and delivery of interventions Teachers reported high numbers of suspected conditions in their classrooms particularly for cases of speech and language needs and dental problems, and the prevalence of suspected conditions was significantly linked to the school social deprivation scores. In this sample, 4% of children were reported as having diagnosed speech and language needs. The national average for speech and language needs is known to be 7% in the general population, but this is thought to rise to as high as 50% in the most deprived areas (Bercow, 2008). Although teachers are not qualified to diagnose developmental and health conditions, they may be identifying those in this sample who are at risk for subsequently reaching the threshold for specialist assessment and intervention and may therefore be a valuable resource for identifying children who potentially have an unmet health or developmental need. The opportunities for health services to work collaboratively with schools may extend to collective delivery of health education and promotion in schools and further training of teachers in identifying and managing health problems. This would respond to the possibly substantial underestimation of conditions such as obesity, reported as being only 2% in this sample, whereas in the local area population of reception age children, it is known to be 22% (NHS Bradford and Airedale, 2012). Although this may be partially due to the non-random sample represented in this study, it is also likely to reflect issues around perceptions of healthy child weights and an area in which further training may be necessary.
School policies and responsibility for managing child health in school Government reforms in the United Kingdom are working to develop interdepartmental collaboration between health and education services (Department for Education, 2012). There was evidence in our results to suggest that school teachers perceive involvement and support from some health services as unsatisfactory and they requested more comprehensive guidance and advice that could be integrated into school practices. The value of the school nurse was recognized and 42% of teachers said they would speak to the school nurse if they were concerned about a child’s health; however, teachers reported wanting more access to school nurses. The school nurse service now works within a public health model looking to ‘prevent and promote’ rather than ‘seek and treat’ health problems (Blair and Debell, 2010). This is supported by evidence from a survey of nurses working in schools in the United Kingdom where the five most common activities reportedly carried 7 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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out by over 90% of nurses were health promotion, staff education, sex education, tackling obesity and attending child protection conferences (Royal College of Nursing, 2009). Comparatively, only 17% of respondents reported administering medication to pupils (Royal College of Nursing, 2009). Although 96% of schools had a policy to guide the management of child health in school, 66% of teachers reported that they did not record medication administration and 68% had received no training in managing child health. This is not in line with the Department for Education and Skills (2005) guidelines, which stress the importance of these practices for child health and safety and to reduce liability. Teachers also reported that medication administration was being carried out by a number of school staff including teaching assistants, lunchtime supervisors and office administrators. It is therefore important that training is targeted at all staff responsible for managing child health and medication administration and not just teaching staff.
Limitations The evidence gathered in this study reflects a sample of reception year teachers from a single city and a relatively small qualitative sample, which may be limiting. In particular, those teachers choosing to respond to the questionnaire and subsequently volunteering to be interviewed may be from classes with particularly high levels of health or developmental issues. The sample represents a diverse multi-ethnic population with deprivation levels that may make the findings transferable to other urban sites; however, further research in other educational settings in different communities would be beneficial to compare teacher-reported experiences.
Conclusion The study used a survey and interviews to explore teacher views on the management of health and developmental conditions in school. Findings suggest that teachers and school staff may represent an underused resource for identifying children with developmental and health conditions and that the connections formed between schools and families may be utilized by other services by delivering interventions in schools where possible. Where most schools use a policy to inform the management of child health in school, some key areas such as training and medication administration documentation may not be followed in practice. Acknowledgements The authors would like to thank the teachers who responded to the questionnaire and those who were interviewed. Funding This article presents independent research funded by the National Institute for Health Research Collaboration for Applied Health Research and Care (NIHR CLAHRC). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Supplemental material The online data supplements are available at http://chc.sagepub.com/supplemental. 8 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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References Allen K, Henselman K, Laird B, et al. (2012) Potential life-threatening events in schools involving rescue inhalers, epinephrine autoinjectors, and glucagon delivery devices: reports from school nurses. The Journal of School Nursing 28(1): 47–55. Bercow J (2008) The Bercow report: a review of services for children and young people (0-19) with speech, language and communication needs. Available at: www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00632-2008 (accessed 27 July 2014) Blair M and DeBell D (2010) Reconceptualising health services for school-age children in the 21st century. Archives of disease in childhood 96(7): 616–618. Canham DL, Bauer L, Concepcion M, et al. (2007) An audit of medication administration: a glimpse into school health offices. Journal of School Nursing (Allen Press Publishing Services Inc.) 23(1): 21–27. Chakraborty RN and Hamer DJ (2005) Survey of medication administration policies within schools in Sheffield. Journal of Child Health Care 9(2): 110–121. Clay D, Farris K and McCarthy A (2008) Family perceptions of medication administration at school: errors, risk factors, and consequences. Journal of School Nursing 24(2): 95–102. Department for Education (2012) Support and aspiration: a new approach to special educational needs and disability: progress and next steps. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/180836/DFE-00046-2012.pdf (accessed 27 July 2014). Department for Education and Skills (2005) Managing medicines in schools and early years settings. London: DfES. Available at: http://www.education.gov.uk/publications/eOrderingDownload/ManagingMedicinesNov07version.pdf (accessed 27 July 2014). Marmot M (2010) Fair society, healthy lives: the Marmot review executive summary; strategic review of health inequalities in England post-2010: Marmot Review. Available at: www.instituteofhealthequity. org/projects/fair-society-healthy-lives-the-marmot-review (accessed 27 July 2014). McCann D, McWhirter J, Coleman H, et al. (2002) The prevalence and management of asthma in primaryaged schoolchildren in the south of England. Health Education Research 17(2): 181–194. McCarthy A, Kelly M and Johnson S (2006) Changes in medications administered in schools. Journal of School Nursing 22(2): 102–107. NHS Bradford and Airedale (2012) Bradford joint strategic needs assessment. Available at: www.observatory.bradford.nhs.uk/P.s/JSNA.aspx (accessed 04 September 2013). Office for National Statistics (2013) Long-standing and limiting long-standing illness or disability. Available at: www.ons.gov.uk/ons/rel/ghs/general-lifestyle-survey/2011/rpt-chapter-7.html#tab-Long-standing-andlimiting-long-standing-illness-or-disability (accessed 27 July 2014). Ritchie J and Spencer L (1994) Qualitative data analysis for applied policy research. In: Bryman A and Burgess RG (eds) Analyzing Qualitative Data. London/New York: Routledge, pp. 173–194. Royal College of Nursing (2009) School Nursing in 2009: Results from a survey of RCN members working in schools in 2009. Available at http://www.rcn.org.uk/__data/assets/pdf_file/0007/275857/003552.pdf Wang H, Liddell CA, Coates MM, et al. (2014) Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the global burden of disease study 2013. The Lancet 384: 957–979. (accessed 27 July 2014) Wong ICK, Awolowo T, Gordon K, et al. (2004) Survey of administration of medicines to pupils in primary schools within the London area. Archives of Disease in Childhood 89(11): 998–1001.
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Teacher-reported prevalence and management of child health problems at primary school
Journal of Child Health Care 1–9 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493515569327 chc.sagepub.com
Anna F Leyland1, Kate E Pickett2, Sally Barber3, Rosemary McEachan3 and John Wright3 Abstract We explored primary school teacher-reported experiences, prevalence and management of child health and developmental problems and medication administration from one multi-ethnic urban community in England. A survey was delivered to 90 reception class teachers in 45 primary schools, and semi-structured interviews were conducted with a purposive sample of eight respondents. Fiftysix percent of teachers completed the questionnaire. Findings suggest that teachers and school staff may represent an underused resource for identifying children with developmental and health conditions and that the connections formed between schools and families could be utilized by other services by delivering interventions in schools where possible. Whilst most schools use a policy to inform the management of child health in school, some key areas such as training and documentation of medication administration may not be followed in practice. Interview findings supported and expanded on survey data by identifying barriers to collaboration between services and families. Keywords Child health, deprivation, medication administration, school, survey design
Introduction Health in early childhood forms a foundation for development and is an important factor for physical, intellectual and emotional well-being (Marmot, 2010). The child mortality rate in the United Kingdom is the highest in the European Union (Wang et al, 2014) and around 21% of
1
Department of Psychology, University of Sheffield, Sheffield, United Kingdom Department of Health Sciences, University of York, York, United Kingdom 3 Born in Bradford, Bradford Institute for Health Research, Bradford, United Kingdom 2
Corresponding author: Anna F Leyland, Department of Psychology, University of Sheffield, Sheffield, S10 2TN, United Kingdom. Email: [email protected]
Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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children aged between 5 and 15 years have a long-standing illness or disability (Office for National Statistics, 2013). Given the amount of time children spend in school, education settings can play a critical role in identifying and managing developmental and health problems in children. The management of child health problems in school is a collaborative effort between health and education services and families. School nurses are an example of integrated working between health and education services; however, most UK schools do not have access to a full-time school nurse service (Royal College of Nursing, 2009). A key challenge for schools is the administration of prescribed medication during school hours. It is important that schools are enabled to manage and administer medication in school safely. The publication Managing Medicines in Schools and Early Years Settings (Department for Education and Skills, 2005) aims to provide a clear framework to inform the development of policies by UK local education authorities and schools. Although most UK schools report having a policy to inform the management of health problems (e.g. Chakraborty and Hamer, 2005; McCann et al., 2002; Wong et al., 2004), research has found that medication is often administered in school by non-health professionals with little to no training (Allen et al., 2012; McCarthy et al., 2006). Evidence from the United States suggest that medication errors commonly occur in school and that some of these mistakes can have a negative impact on a child’s ability to learn or socialize and can harm their physical or mental health (Canham et al., 2007; Clay et al., 2008; McCarthy et al., 2006). Young children at school may be disproportionately affected by any errors as they may lack the skills to manage and administer their own treatments. Existing evidence highlights the importance of research in this area; however, the vast majority has originated from the United States, and there is a need for research representing countries with differing public service systems, such as those in the United Kingdom.
Objective The objective of the study is to gain an understanding of child health and development in an education environment across the following four overarching areas: (1) teacher-reported prevalence of health problems and treatments received in school, (2) medication administration in school and the policies and procedures that support the management of child health conditions, (3) teacher practices and experiences of meeting child health needs and how this fits with the wider role of a teacher and (4) systemic processes around the child that support or hinder the school staff members’ ability to manage child health needs. These overarching themes were identified by school representatives who attended a Born in Bradford cohort study consultation event. Time of school entry was also highlighted as a critical period for child health and development as school staff learn about children’s additional needs and can play a key role in identifying undiagnosed or emerging conditions. The impact of social deprivation on these overarching areas was also considered. The following research questions fit with the four overarching themes: (1) How many children do teachers report as having suspected or diagnosed health and developmental conditions and how many children receive treatments in school? (2) What policies and procedures exist to support the management of child health conditions and medication administration in school and are these policies followed in practice? (3) How do teachers feel about working to meet child health and developmental needs, delivering medications and what impact do they see this responsibility having on the classroom? (4) How does working with other systems around the child support or hinder the school staff’s ability to successfully manage child health and developmental needs? 2 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
Leyland et al.
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Methodology The study used a mixed-methods design where research elements were conducted sequentially (questionnaire and semi-structured interviews) with equal emphasis being placed on the findings of each method. This approach was taken to gather a systematic description of the issue under consideration. The questionnaire provided a breadth of understanding about the prevalence and management of child health conditions and identified systems supporting these processes. The interviews complemented and elaborated on the survey results by enabling exploration of teacher experiences of managing child health conditions in school. The findings from each methodology were combined at point of presentation of results to reflect the interdependent nature of the findings. Mixing results at this point offers greater profundity of the findings and overcomes the limitations of data gained from the survey by presenting alongside it the complementary findings from the interviews, and vice versa.
Development of questionnaire and interview schedule The main items of the questionnaire and interview schedule were developed interdependently following a literature review and consultation with school representatives. The literature review supported the development of the questionnaire and interview items through two means (1) topics and tools were identified that had previously been utilized and explored (e.g. medication administration by non-medically trained staff; identifying whether a policy exists to inform medication administration) and (2) identifying gaps in the existing literature (e.g. lack of description of issue from teacher perspective). Further to this, expert opinion on the items was gained through consultation with co-authors. The questionnaire was refined following a pilot with four primary school teachers and the interview schedule abbreviated and simplified following a pilot with one primary school teacher. All pilot data were excluded from further analysis. The interview schedule and questionnaire were designed to address the same four overarching research areas, namely, prevalence, medication administration, teacher experiences and systemic processes. Prevalence. Teacher-reported prevalence of child health and developmental conditions was explored with three questionnaire items regarding formally diagnosed and suspected conditions and the treatments being administered in school (e.g. ‘As far as you are aware, how many children in your class have the following health problems?’, followed by a list of 18 common condition problems, e.g. asthma). Medication administration. Six questionnaire items asked about school processes and procedures for administering and storing medications (e.g. ‘Who is responsible for the delivery of medications to your pupils?’). The interview schedule asked two complementary questions on this topic to elicit more information (e.g. ‘Where are medications and inhalers stored at school?’). Teacher practices and experiences. Three questionnaire items focused on teacher experiences and practices (e.g. ‘How confident do you feel about meeting the health needs of the children in your classroom?’) and this area was explored more fully through three interview questions (e.g. ‘Do you ever give out medications or treatments, like inhalers? If so how do you feel about doing it?’). 3 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Systemic processes. Two questionnaire items explored the concept of systemic processes (e.g. ‘If you had a concern about an ongoing health problem of a child, what would you do?’) and this was supplemented by two interview questions (e.g. ‘If a child has a suspected or diagnosed condition how do you work with families to meet the child’s needs?’).
Data collection Staff from 45 of 157 primary schools in a multi-ethnic city in the north of England were invited to participate. Questionnaires for teachers of each reception class (N ¼ 90; children aged 4–5 years) in the school were hand delivered to and collected from administrative staff. Teachers could opt in to be contacted about an interview by providing their email address at the end of the questionnaire. If teachers chose to not give contact details then participation could remain anonymous. The first eight teachers to return the questionnaire provided contact details and when contacted gave their consent to be interviewed. No further teachers were contacted. Interviews were conducted in school and lasted 20–30 minutes.
Data analysis Questionnaire data were coded, processed and analysed using Statistical Package for Social Sciences version 21.0 for Macintosh. Semi-structured qualitative interview audio recordings from eight participants were transcribed in Microsoft Word and analysed using framework analysis (Ritchie and Spencer, 1994).
Ethics The project was given ethical approval by the University of York’s Health Sciences Research Governance Committee.
Results The response rate to the questionnaire was 56% (50/90), which represented 60% of schools contacted (27/45). Findings from the questionnaire and interviews are presented together grouped into the four overarching themes of the research, namely, prevalence, medication administration, teacher experiences and systemic processes, to ensure enhanced understanding of each theme.
Prevalence of health and developmental conditions Teachers’ average reported prevalence of diagnosed and suspected health, developmental and behavioural conditions are presented in Figure 1 and specific health, developmental and behavioural conditions and special educational needs are shown in Supplement Table 1. Average suspected conditions in reception classes in each participating school (N ¼ 27) were significantly correlated with school deprivation on three indicators (Supplement Table 2). All data for this theme were gained through the questionnaire. 4 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
Leyland et al.
5
Median children per class
14 12 10 8 6 4 2 0 Diagnosed conditions
Suspected conditions
Treatments in school
Figure 1. Median numbers of children per class reported by teachers as having a diagnosed or suspected health or developmental condition and those receiving treatments in school; error bars show 25th and 75th percentile.
Medication administration The responses to the questionnaire covering medication administration, teacher training and responding to an unmet child health need are presented in Supplement Table 3. The majority of teachers reported a school policy informing the management of health problems (96%); however, fewer reported documenting medication administration (66%). Despite the low amount of training overall, most respondents reported that they felt they did not need any more training (58%). However, the interview findings indicated that more training may occur in school than was reported in the survey. Each school will respond to the pupils that they’re getting in and because we seem to be picking up the autistic pupils I need to put the support in for staff and we’ll have the training. (Participant 5)
Teacher practices and experience of managing child health needs Overall teachers’ average rating of confidence was high for meeting the health needs of their class (M ¼ 5.6, SD ¼ 1.1; 7 ¼ most confident) and delivering medications (M ¼ 5.4, SD ¼ 1.8) as reported in the questionnaire. In interviews, teachers talked about how teaching experience, knowledge of child health and development, conducting research and targeted training had equipped them to manage child health problems and reduce the impact on the classroom. In terms of it affecting the teaching it [a child needing their nappy changed] did in a way cause you had to stop what you were doing to go manage it. But like I say they’re young it happens, we’re used to it . . . but because I’m used to it I’ll make sure that what needs to get done gets done. (Participant 4)
Teachers had a holistic view of children and so considered meeting a child’s health needs as part of their role, although they acknowledged that at times they were performing duties that extended beyond the ‘role of a teacher’ and these duties caused discomfort for some teachers and staff. You kind of feel like your role is a bit more than a teacher now because your role is that you’re a parent and a social worker and a doctor and a nurse and everything else, so it’s a lot more demanding than I think people think. (Participant 6) 5 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Questionnaire results reported health conditions as not impacting greatly on the classroom (M ¼ 4.6, SD ¼ 2.l; 7 ¼ least impact). Interview findings identified areas, such as tiredness, poor concentration, low attendance, challenging behaviours due to pain or discomfort and not being able to take part in outdoor activities, where health conditions can impact on the children at school. A girl in my class that’s got quite severe asthma and has spent [a lot of time] in hospital because of it, so she missed a lot of time from school. (Participant 4)
Systemic processes Questionnaire data indicated that more support was desired from educational psychologists, school nurses and specialist health-care practitioners. Teachers reported that in response to a perceived unmet health need they would most commonly act to access specialist advice from others teachers within school, school nurses and by liaising with families (Supplement Table 3). These reported actions were supported in interview reports. We’ll get a team involved where we’ll speak to parents, chat to the school nurse, see if there’s anything that’s come up in their history or [from] home visits. (Participant 4)
Interviews revealed that the school nurse service was viewed as being an effective means of working between health and education services and with families. However, teachers reported that it would be beneficial if health and specialist services could offer more comprehensive advice and guidance directly to schools. So we do work with the school nurse a lot in terms of dietary needs, generally because children are very underweight or very overweight. So we work with her. We currently have one example, we’re filling in a food diary and we’ve asked at home for them to do the same thing . . . . (Participant 1) We often have to chase [child health information] up, it often has to come from us to find out. If it’s kind of a smaller health issue then we have to find that out. If it’s something big then it’s usually quite good, the hospitals are quite good at sending off information about things. (Participant 1).
Teachers reported barriers in health and specialist service accessibility, particularly, with families not feeling listened to by professionals, indirect referral pathways, service responses to missed appointments, waiting lists and indirect information sharing, that is, to school via families. The importance of forming strong relationships between the school and the family was emphasized as being beneficial for child health and well-being. Effective links were often identified by frequent communication, often on the playground before or after school, and the use of diaries or notes passed in child book bags. The speech and language [therapy team] has been the hardest one to work with, if parents miss an appointment they’re dropped off the system and then trying to get them back on the system it’s a long waiting time again. (Participant 4) If you form that relationship with them [parents], I think that a lot of them do get less defensive and I do think that a lot of them do take up what you have to say and do take your advice but I think it’s gaining their trust and confidence first and especially if they’ve had a negative experience of school themselves they’re not going to come anywhere near. (Participant 4). 6 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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Barriers to communication and collaboration with families included when families do not pick up their children from school, where they had untrusting feelings towards schools in general and language barriers. Barriers were overcome through home visits, the use of translators, verbal communication rather than written and employment of family liaison workers. Especially at this age, first year of school, you’ve got to get that communication there, cause you know it’s little things like, if a parent can just tell you that they haven’t slept very well or that they’re just tired, or that they have had a bad night with asthma then it just puts those pieces together in the jigsaw puzzle really. (Participant 4)
Discussion Interdepartmental collaboration for early identification of child health problems, health education and delivery of interventions Teachers reported high numbers of suspected conditions in their classrooms particularly for cases of speech and language needs and dental problems, and the prevalence of suspected conditions was significantly linked to the school social deprivation scores. In this sample, 4% of children were reported as having diagnosed speech and language needs. The national average for speech and language needs is known to be 7% in the general population, but this is thought to rise to as high as 50% in the most deprived areas (Bercow, 2008). Although teachers are not qualified to diagnose developmental and health conditions, they may be identifying those in this sample who are at risk for subsequently reaching the threshold for specialist assessment and intervention and may therefore be a valuable resource for identifying children who potentially have an unmet health or developmental need. The opportunities for health services to work collaboratively with schools may extend to collective delivery of health education and promotion in schools and further training of teachers in identifying and managing health problems. This would respond to the possibly substantial underestimation of conditions such as obesity, reported as being only 2% in this sample, whereas in the local area population of reception age children, it is known to be 22% (NHS Bradford and Airedale, 2012). Although this may be partially due to the non-random sample represented in this study, it is also likely to reflect issues around perceptions of healthy child weights and an area in which further training may be necessary.
School policies and responsibility for managing child health in school Government reforms in the United Kingdom are working to develop interdepartmental collaboration between health and education services (Department for Education, 2012). There was evidence in our results to suggest that school teachers perceive involvement and support from some health services as unsatisfactory and they requested more comprehensive guidance and advice that could be integrated into school practices. The value of the school nurse was recognized and 42% of teachers said they would speak to the school nurse if they were concerned about a child’s health; however, teachers reported wanting more access to school nurses. The school nurse service now works within a public health model looking to ‘prevent and promote’ rather than ‘seek and treat’ health problems (Blair and Debell, 2010). This is supported by evidence from a survey of nurses working in schools in the United Kingdom where the five most common activities reportedly carried 7 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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out by over 90% of nurses were health promotion, staff education, sex education, tackling obesity and attending child protection conferences (Royal College of Nursing, 2009). Comparatively, only 17% of respondents reported administering medication to pupils (Royal College of Nursing, 2009). Although 96% of schools had a policy to guide the management of child health in school, 66% of teachers reported that they did not record medication administration and 68% had received no training in managing child health. This is not in line with the Department for Education and Skills (2005) guidelines, which stress the importance of these practices for child health and safety and to reduce liability. Teachers also reported that medication administration was being carried out by a number of school staff including teaching assistants, lunchtime supervisors and office administrators. It is therefore important that training is targeted at all staff responsible for managing child health and medication administration and not just teaching staff.
Limitations The evidence gathered in this study reflects a sample of reception year teachers from a single city and a relatively small qualitative sample, which may be limiting. In particular, those teachers choosing to respond to the questionnaire and subsequently volunteering to be interviewed may be from classes with particularly high levels of health or developmental issues. The sample represents a diverse multi-ethnic population with deprivation levels that may make the findings transferable to other urban sites; however, further research in other educational settings in different communities would be beneficial to compare teacher-reported experiences.
Conclusion The study used a survey and interviews to explore teacher views on the management of health and developmental conditions in school. Findings suggest that teachers and school staff may represent an underused resource for identifying children with developmental and health conditions and that the connections formed between schools and families may be utilized by other services by delivering interventions in schools where possible. Where most schools use a policy to inform the management of child health in school, some key areas such as training and medication administration documentation may not be followed in practice. Acknowledgements The authors would like to thank the teachers who responded to the questionnaire and those who were interviewed. Funding This article presents independent research funded by the National Institute for Health Research Collaboration for Applied Health Research and Care (NIHR CLAHRC). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Supplemental material The online data supplements are available at http://chc.sagepub.com/supplemental. 8 Downloaded from chc.sagepub.com at University of Liverpool on December 10, 2015
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