Case study

Jacqueline Ombler is a 49-year-old School Nurse Team Leader based in Hessle, East Yorkshire. Jackie has 17 years' experience of school nursing but originally worked as a ward sister before she had her two children. Jackie is also a registered general nurse, a registered nurse for adults, a qualified family planning nurse and a community public health nurse. Her work covers 25 primary schools and three senior schools in Eastern Hull and is primarily a public health role, raising awareness of the importance of healthy living and making informed decisions.

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There are only around 1,200 school nurses and about 20,000 primary and secondary schools in the UK. The Government has launched a drive to raise low numbers of health visitors, but school nurses have lagged behind.

Laura: What is involved in being a school nurse?

Jackie: Overall, school nursing is focussed on holistic health needs assessment of individuals and safeguarding responsibilities. We liaise with pupils, schools, parents and other agencies. It is a public health role and we partake in vaccination programmes and often conduct PSHE (Personal, Social and Health Education) lessons at schools, helping to fit health into the curriculum. In Hull we're a bit different because we work for City Health Care Partnership (CHCP) and offer all schools a universal corporate programme as well as the opportunity to buy in extra school nursing time to meet their needs, called School Health Plus. We also support the National Child Measurement Programme, which is a Government initiative looking at obesity trends. It's not just about collecting data but assessing the child individually and picking up on the children who need extra help or have growth abnormalities. Public health in Hull is built around six outcomes for children and young people and our work is based on helping children grow up healthily, grow up safely, achieve, enjoy life, reach economic wellbeing and contribute positively to society.

Laura: What oral health advice do you give children?

We don't actually open the mouth but can still observe decay and if we see arching from where a dummy's been then that will all be followed up and documented.

Jackie: We stress the importance of regular dental check-ups and advise not to ignore toothache. We get consent from the parents to give us their children's health information and if the child is not registered with a dentist we try to address that by generating a letter that includes a list of registered dentists within Hull.

We talk to children about how to brush their teeth, how often and for how long and how much toothpaste is required. We advise them not to rinse after brushing their teeth and to change their toothbrush regularly.

We also give dietary advice on issues such as the dangers of hidden sugars, taking sugars with meals and reducing snacking, and promote water and milk over carbonated drinks.

Laura: Has the oral health advice you give changed over the years?

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Jackie: In some ways it has with research. A lot of children have electric toothbrushes now, but you still have to remind them to brush their teeth for two minutes and not up and down but in a circular motion. There has been increasing focus on looking after the gums as well as the teeth, so we emphasise the need to care for the gum margins too. Most importantly advice on rinsing has changed. In the past the old method was to rinse at the end of brushing, which removes the effects of the fluoride. We're not in a fluoridated water area, so it makes it even more important not to rinse.

Laura: Have children's teeth changed over the years you have been a school nurse?

Jackie: I think it has remained pretty much the same, with a certain portion of the population still having a large amount of dental decay. Shockingly we're still seeing children have a full dental clearance and in these cases the dentists do make us aware of these families. When we assess children at school and the school health advisors complete the National Child Measurement Programme the teeth are also looked at. We don't actually open the mouth but can still observe decay and if we see arching from where a dummy's been then that will all be followed up and documented.

There was a period when dentists were very difficult to access, but now there is no reason why a child shouldn't have a dentist. Dental health is often taken less seriously, with parents passing on phobias and dental scare stories to their children. We've got better facilities in schools now for children who do either have phobias or special needs, so dentists can access these children when they normally wouldn't even get through the practice door.

Laura: How do you feel about the Brush Bus Initiative? (a supervised toothbrushing programme in schools)

When children come back into the classroom after their lunch break their toothbrush is in their seat with a pea-sized amount of toothpaste on a hand towel.

Jackie: I think it has a very, very significant impact. For those children who don't even have their own toothbrush at home, the initiative means that they are at least brushing their teeth once a day. When children come back into the classroom after their lunch break their toothbrush is in their seat with a pea-sized amount of toothpaste on a hand towel. While the teacher is doing the register, the children are brushing their teeth while watching a DVD with a two-minute countdown. It's set up for free through sponsorship from local dentists and there has been a massive uptake of the initiative in primary schools. It does involve a bit of extra time in the classroom but obviously it reaps good rewards and children get into good habits. The importance of tooth brushing is reinforced by making it a group activity and set routine.

Laura: What five things do you think can be done to improve oral health and oral health awareness in schools?

Jackie:

  • Uptake of the Brush Bus by schools that aren't involved would be of great benefit, though the key is ensuring that schools don't incur costs: they need to be sponsored

  • Better and more consistent policies on packed lunches would highlight the link between good diet and good oral health. Within our experience we have to try and support schools in developing policies, so that they are more restrictive on what can be placed in lunch boxes. Getting rid of vending machines and placing more water fountains in schools would also help

  • Schemes like breakfast clubs really help improve the nutrition of children. It makes sure children are receiving a breakfast before they come to school and reinforces the idea that diet is integral to general and oral health. Most schools in Hull operate a breakfast club now, including senior schools

  • Encouraging dental practices to sponsor schools is an excellent way of making sure children receive the dental support they need. One school in Hull works very closely with a dental practice and the dentists are very accessible - they even had a coffee afternoon at the school that parents could attend so that the dentists could put across their concerns and give parents advice. Good oral health habits are established at a young age and many parents are often unsure about what age to start brushing children's teeth or what age children should be brushing their own teeth. Parents should at least check hard to reach areas and support the child until they are confident

  • Resources for both children and parents should be readily available. Help should be at hand to ensure parents obtain a dentist for their child. The community dental health promotion team have a box of visual aids that schools can borrow, which makes learning about oral health more interesting to children.

Laura: How can you get children interested in oral health?

Jackie: Younger children have shorter attention spans, so oral health promotion always has to be tailored to who you're talking to. It can't be one size fits all: it has to be bespoke for the age and ability of the children. You can turn the lessons into everything from science to maths: counting how many teeth you should have, how many you will have by a certain age etc. Drawing and singing can similarly be useful learning tools. I also think getting external people into school, such as a school nurse, dentist or hygienist, garners a better response from children, because it's different from their normal class and they remember it as a special day. Children take notice of people's enthusiasm for a subject area and specialists will already have appropriate visual aids and the ability to put the information across well. Older children love hands-on experiments and are amazed if you put a tooth in a bottle of cola and they can actually see it eroding. For children in foundation two if there's a dressing up corner in their class with themes such as 'at the dentist' then they can act out a dental visit in a non-threatening way.

Laura: With the dangers of sugars featuring more and more in the press have you noticed a particular focus on obesity, caries and related issues reflected in health education at schools?

Jackie: Schools have looked at policies to see how they can impact on child health. It can be as simple as being extra stringent with healthy packed lunch boxes and ensuring there are more activities available at playtime, so even if it's just a quick ten minute break in the morning there is more structured play. The Enhanced Healthy School Award is a big plus for the schools and in order to retain that they have to consistently meet the criteria of having healthy lunches, water availability and healthier food options.

Laura: What do you think has been the best health campaign in recent years?

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Jackie: Change4Life has been really good. It's eye catching, bright, user friendly, relates to all age groups and is focussed on everyone. There's specific information for parents on exercises and diet. We use and promote the campaign a lot. It's constantly updated and changes with the seasons, with ideas for picnics in summer and back to school lunches in September. It is something that the whole family do rather than just being aimed at the child, which is really important for reinforcing the idea that it is a lifestyle change. National Smile Month is also good, promoting a good dental health message.

Laura: Would you support a new proposed ban on lunch boxes so that all children were forced to have school meals?

Jackie: No, because I think it would cause uproar. Also school meals are currently not diverse enough. If a child is vegetarian it doesn't mean they will always like the one veggie option offered to them and similarly with diets such as kosher, we have to accommodate people who either due to faith or choice can't just conventionally access the normal school meals. Since the horsemeat scandal parents think it's the cheapest of the cheapest foods that are used in school meals, but there's a great difference between one school and the next in quality of food and it's not always clear what you're buying into. In a lot of schools they insist that once pupils finish eating packed lunches they don't empty their box but just close it back up so parents can monitor what's being eaten, which can reassure a lot of parents. When my children were at senior school they had a mixture of school meals and packed lunches and just chose. One of my children was known as fruit face because she had that much fruit in her packed lunch! It's not always a good thing to have so much, but she just loved her fruit. If my children were at primary school again I think I'd want them to try school meals as it's more sociable to eat with peers and there is a much more varied choice now, with things like salad bars, which I don't remember much of myself as a young child. Some schools are doing a trial where the school meals menu is sent home so that the parents can choose what they want their child to have and then the child gets a coloured bracelet so that when they go to the canteen it corresponds with a dish. That means schools can buy in the actual food they need and no-one is disappointed.

Laura: With regard to a recommended ban on 'guilt lanes' in shops, recently Health Minister Anna Soubry said it was up to individuals to 'lead healthy lives' and supermarkets should be able to stock their shelves however they like. Do you agree?

Jackie: I don't think supermarkets should be able to stock guilt lanes - when you're taking children shopping it's always a stressful time for the parents anyway, but if you know where the sweets aisle is you can navigate children away from it. When you're forced to stand in the queue to pay I think it's very wrong to put sweets there. You never see any alternative healthy food there. Manufacturers should be more responsible, as it's tempting enough for adults, let alone children. Legislation should be introduced, like it was with tobacco, with cigarettes now being hidden from view.

Laura: Who do you think is responsible for child dental health?

Jackie: I think foremost the parents but everyone nationally has a responsibility to try and improve children's dental health. If everyone took part of the responsibility it would reduce costs to the NHS for dental treatment and reduce the number of children being put through unnecessary treatment. There are obviously children who have weaker teeth or teeth that are going to need intervention for whatever reason, be it accidental damage or damage through other areas, but children are the parents of the future, so they have to be made aware of the necessity of good oral health.

SEE ALSO: Interview with a health visitor: www.nature.com/vital/journal/v10/n3/full/vital1688.html