Eva Clausson

Author: Eva Clausson,
RNT, MSc, Doctoral candidate
Faculty of Health Science
Kristianstad University, SE-291 88 Kristianstad, Sweden and Nordic School of Public Health, Göteborg
Phone +46 44 20 40 34, e-mail Eva.Clausson@hkr.se

Main supervisor: Professor Lennart Köhler, MD, Nordic School of Public Health, Box 12133, SE-402 42 Göteborg Sweden. lennart@nhv.se

Co supervisor: University Lecturer Agneta Berg, RMN, RNT, MSc, PhD, Kristianstad University, Department of Health Sciences, SE-291 88 Kristianstad Sweden, Phone +46 44 20 40 76, agneta.berg@hkr.se

Background
An alarming increase in psychosomatic symptoms and long-term illnesses among schoolchildren has been shown in recent reports. The increase has been especially steep in the Nordic countries since the 1970s. The accelerating stress in society, combined with economic strains and changes in family structures can be important factors contributing to this development. The effects of the increased ill health are seen in many areas, but most remarkably in school.

In a pilot study twelve school nurses were interviewed about their views of schoolchildren's health (Study I). According to the nurses the schoolchildren's mental health problems were increasing although they were physically healthy. The nurses meant that the schoolchildren's health/ill-health was related to the individual, the family and the school.

The family seemed to be the most important factor for the schoolchildren's health status. The objectives of the School Health Service (SHS) in Sweden are "to follow, maintain and recover the pupils' physical, mental and social health". The communities have the responsibility for the SHS which is part of the school system. The nurse together with the physician mainly carries out the child health program. The school nurse is the key person and continues the health surveillance and immunisations during the school-age period from 6-7 to 19 years of age.

There seem to be a lack of studies focusing on schoolchildren's health from a school nurse perspective. It appears to be necessary to increase the scientific activities in the area to attend to these problems. The aim of the project was to survey the school nurses judgement of schoolchildren's health, their attitude towards documenting it in the school health care record, and to investigate the usefulness of family nursing models from Canada in a Swedish care context.

The studies are accomplished and considered to generate the following five papers:

Results
Paper I.
Clausson, E., Petersson, K. & Berg, A. School nurses view of schoolchildren's health and their attitudes to document it in the school health record - a pilot study. Scand. J. Car. Sci.; 2003; 17, 392-398.

Abstract
This study highlights school nurses' view of schoolchildren's health and their attitude to document it in the school health records. A strategic sample of twelve school nurses was interviewed. The interviews were semi-structured and analysed with qualitative content analysis. The findings showed that the school nurses' viewed schoolchildren as physically healthy although they called attention to growing problems related to a changed lifestyle. Psychosocial ill-health was however increasing and the most common reason for visiting the school nurse was psychosomatic expressions. According to the nurses' descriptions, health was related to the individual, the school and the family situation. The family situation was mentioned as one of the most important factors of schoolchildren's health. The nurses described no problem to document schoolchildren's physical health. Ethical consideration, tradition, lack of time and the structure of the record were however factors that were said to hinder the documentation of the psychosocial health. In order to promote, protect and recover schoolchildren's health, more research is needed about how beliefs, experience, ethical consideration and resources influence the school nurse's daily work with schoolchildren's health.

Key words: School nursing, school nurses' experience, schoolchildren's health, school health records, family, interview, qualitative content analysis.

Preliminary results
Paper II.
Clausson, E., Berg, A. & Köhler, L. (2005). Schoolchildren's health as judged by Swedish school nurses – a national survey. Manus.

Abstract
An alarming increase in psychosomatic symptoms and long-term illnesses has been shown in recent self-reports among schoolchildren. The aim of the present study was to survey the school nurses judgement of schoolchildren's health on a national base. A mail questionnaire, was distributed to a representative, random sample of Swedish school nurses (n = 183). Data were analysed statistically and by manifest content analysis. Preliminary results shows that Swedish school nurses judged the schoolchildren as predominantly healthy but the mental health had deteriorated during the past two years with increasing psychosomatic symptoms, especially among girls. The given reasons for children's psychosomatic complaints were, according to the school nurses, to a great extent, family related problems. The results indicate that school nurses have genuine knowledge of schoolchildren's health. School nurses are continuously close to the children and meet them several times during the school age period. School nurses seem to be an unutilized source of knowledge of schoolchildren's health, in research as well as in practical school health care.

Keywords: Family, Mental health, Psychosomatic, Schoolchildren, School nurse

Paper III.
Clausson, E., Berg, A. & Köhler, L. (2005). Documenting schoolchildren's health – a matter of concern for Swedish school nurses (National survey – 2005) Ongoing analysis.

Abstract
The aim of the study was to illuminate the documentation of schoolchildren's health in the school health care record from the school nurses' perspective on a national basis. Preliminary results shows that 10 % of the nurses reported difficulties to document schoolchildren's physical health and 50 % of the nurses reported difficulties to document schoolchildren's mental health. According to the nurses they had remarkable difficulties to document sensitive information on psychosocial problems in the schoolchildren's homes although the parents can demand to read the records. Also suspicion about abuse or outrage were considered as difficult to document in the SHCR as well as suspicion about/or unwished pregnancy when the girl don't wish to involve the parents.

Paper IV.
Clausson, E., Köhler, L. & Berg, A. (2005). Documenting schoolchildren's psycho social health - a challenge for school nurses. (Focus group interviews - 2004). Ongoing analysis.

Abstract
Documenting schoolchildren's mental health can be a challenge for school nurses. The aim of the study was to deepen the knowledge of hindrance and opportunities when documenting schoolchildren's psychosocial health. Three focus group interviews were accomplished with a strategic sample of active school nurses (n= 4-6). The interviews were analysed with qualitative content analysis.

Paper V.
Clausson, E. (2005). Family sessions in school health care – a useful tool for improving schoolchildren's psycho social health - a case study. Manus.

Abstract
Psychosomatic complaints and emotions of depression have increased since the seventies among schoolchildren, especially among girls. The health and well-being of children is a multifactor issue, involving individual traits, family networks and social structures. School nurses can be in an ideal position to identify and meet these problems. The aim of the multiple case study was to investigate the usefulness of family nursing models from Canada, modified in a Swedish school health care context, when dealing with recurrent psychosocial illness among schoolchildren. Three family sessions, using genograms and ecomaps, were conducted with two contrasting cases. The Strengths and Difficulties Questionnaire was used as pre and post test. Closing letters where send to each family. The children and their families experienced relief, they felt confirmed and that their feelings and reactions were normal in an abnormal situation. They felt aware of their own strength and possibilities. The SDQ showed an increased well-being after the sessions from both the schoolchildren and the parents' point of view. It is assumed that family interviews can be one valuable tool that school nurses can use when handling recurrent, psychosocial illness among schoolchildren.

Key words: Psychosomatic, schoolchildren, psychosocial health, school health care, family sessions, SDQ, Closing letter