A heavy toll

A heavy toll was the fourth category in the shared common problem of untenable burden and was articulated in words and in expressed emotions. More than one

participant became tearful during the interview. One interview was terminated due to participant distress, but the participant was emphatic that their data be included, citing their distress as a motivating factor for participating. Some participants identified a heavy toll directly: “I’ve been dealing with some really heavy, heavy cases. It’s taking a toll on me” (P15); “The only thing that would make me consider not doing the job anymore is [that] it takes a toll” (P24). Throughout participant interviews the word “heavy” arose over and over again: “it does weigh heavy on me because I want that child to be safe” (P11).

I’ve had teachers ringing up [and] saying to me ‘I can’t believe this kid’s just told me this, can I bring them down to you?’ Then [the teacher has] needed support as much as the child has. Sometimes it’s a heavy load to carry. (P31) I felt burnt-out after a while. I was sometimes doing more than one [suicide risk assessment] a day, which is a really heavy load to talk about that sort of issue. Then [I have to] talk to the parents, follow the whole thing through, write the whole thing up. It’s quite heavy. (P3)

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A heavy toll was also articulated by other participants using different words: “we’ve

got students who’ve attempted suicide, they're behaviour… it’s really very

distressing” (P22); “it’s horrible when you have to make that phone call and actually have that conversation [with the parent about the young person’s suicide risk]’ (P20); “I'm dreading… again I'm feeling the emotions come [participant tearful]. I'm

absolutely dreading there being a suicide, and I feel like it’s coming” (P7).

It was clear that a heavy toll was more than work stress. It reflected the vulnerability of young people and the uncontrolled nature of the stresses participants experienced. A participant who had been employed in another high stress nursing position offered the following:

What I’m exposed to at the secondary school is as traumatic, if not more so [than my previous employment in the hospital], because we’re dealing with… children who are… in very difficult situations. In a hospital environment it’s quite controlled, quite contained. (P31)

At times, a heavy toll was so burdensome that participants felt they could not continue. A participant recently returned to secondary school nursing after an extended period of leave explained what led to the request for leave:

[I was caring for] a 12 year old Chinese boy… I said “I need to contact your parent.” [He said] “Oh, they’re in China.” [I said] “Who’s at home?” “The dog” “So you’re home alone?” “No, I have the dog.” “No, an adult, a

person?” “No, the dog” “So you’re alone?” “No, not alone.” I got to the point where I [needed] a break from the role for a little while. (P6)

A participant who was undertaking alternative employment at the time of interview specifically named vicarious trauma as contributing to a heavy toll:

I've [been in alternative employment] for six weeks [and] I haven’t asked anybody if they're going to take their own life. That’s massive [highly

significant to me]. I feel my emotion, the vicarious trauma is quite high in me at the moment…. It affects what I watch on the television. I can't watch any

violence, violence towards women, children, that kind of stuff, because I deal with so much mental health [in my school nursing role] every day.” (P7) An especially painful source of a heavy toll was the tension between the relationship- building and reporting aspects of the secondary school nurse role. These twin duties were often incompatible and sometimes severed the relationship that had facilitated the reporting. One participant described a heavy toll in relation to a group of young Aboriginal women who had made a disclosure to the participant that had to be reported to the Department for Child Protection and Family Support:

I feel very torn between being an advocate for these children and supporting them and building relationships which is a hard thing to do. They feel betrayed by you because you’ve reported to the authorities. There’s an investigation [by the Department for Child Protection and Family Support] and then they get in trouble [with their families] and stop seeing you. (P31) Although participants did not report feeling that their duty of care extended beyond the school setting, it was evident that participants often felt a strong obligation to intervene assertively in an attempt to prevent harm both in and out of school. This commitment had the potential to precipitate a heavy toll when they felt impotent in the face of the perceived failures of other service providers. One participant

recounted a case where a 15 year old student with significant mental health problems had recently become homeless:

The chaplain and the [deputy] principal went to meet this girl in [suburb], and they’d asked myself and the psychologist’s advice. We both said, “get her to a hospital” … They managed to get the girl to the hospital, and she was discharged. She did see a social worker, she did get a Child and Adolescent Mental Health Services referral, but I felt somebody needed to take care of this 15 year old child that had been saying to men “I’ll have sex for money.” Covered in self harm, both arms, and I sometimes feel a bit let-down. (P29) A similar sentiment was echoed by a participant who had identified that a young adolescent was being groomed by an adult external to the school for the purposes of future sexual gain. Becoming tearful, the participant reported:

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There’d been a disclosure of grooming, which had been reported [to the Department for Child Protection and Family Support]. [The] worker said to me “well, grooming is not illegal in Western Australia.” [Participant indicates outrage] ‘So it’s okay then? Alright.’ Do you know what I mean? So, I’m thinking, ‘who has protected this child? Nobody’. (P31)

The heavy toll participants experienced was not limited to circumstances where the young person was enrolled at the school. Reflecting on a case where a young person with mental health problems was sent interstate against his will, the participant reported:

The family uprooted [the student] and sent him back to the [origin] of his problems in Queensland [4000 kilometres from Perth]. He ended up in [the psychiatric] hospital for two weeks… I was really worried about his

wellbeing. I thought he was going to [die by suicide]. (P6)

Similarly, although participants were often reassured when a young person was receiving specialist care, this did not prevent the experience of a heavy toll: “I do feel concerned for students sometimes… five suicide attempts recently… known to [the] Child and Adolescent Mental Health Service. They’ve got all that support, [but] still they’re doing these sort of things [attempting suicide]” (P11).

3.7 Summary

This chapter identified that participants shared the basic social psychological problem of untenable burden. Analysis of the data identified four categories that contributed to participants’ experience of untenable burden, including the

complexity of the difficulties young people faced, the intense workload, the risk of devastating outcomes such as suicide, the autonomous nature of clinical practice and the emotional burden of the work. These were conceptualised as 1) wicked problems, 2) persistent intensity, 3) autonomy and isolation, and 4) a heavy toll.

Wicked problems conceptualised participant reports that young people presented with

difficulties that were complex, multidimensional, not easy to resolve and frequently resistant to intervention. Distress and other symptoms of mental health problems

were a common reason for visits to the school health centre, and the majority of participants had contact with young people experiencing mental health problems on a daily basis. While participants endeavoured to refer young people with significant mental health problems to specialist services for treatment, this did not always result in fewer visits to the school nurse. Participants spoke at length about young people with whom they had frequent or ongoing contact, sometimes over years. The second category in the shared common problem of untenable burden was therefore

conceptualised as persistent intensity.

The third category in the basic social psychological problem of untenable burden was autonomy and isolation. Faced with daily exposure to complex problems and young people in difficulty, participants reported that the high level of autonomy and

isolation contributed to high levels of personal and professional stress that impacted

on their wellbeing and their capacity to sustain the role’s demands. The high level of work-related stress participants experienced in their role was conceptualised as a

heavy toll, the fourth and final category in the basic social psychological problem of untenable burden. Chapter four of this thesis will examine the conditions that