Research

Effective sex education in primary schools: A study

ex education is one of the most contentious areas of both health and educational activity in schools (Kirby et al, 2007). The remit of sex and relationship education (SRE) encompasses a range of issues, including: Relationships Physical and emotional development Resisting peer pressure Building self-esteem. However, discussions in the public domain focus primarily on the narrow issues of sexual behaviour and young people and reflect ongoing social tensions around the effect that sex education may have on the behaviour of children (Kirby, 2006; Bleakley et al, 2006; Denny and Young, 2006). Sex education has its detractors among those taking a moral stance arguing that sex education promotes sexual activity, as well as its supporters who argue for pragmatism in the face of rising teenage pregnancy rates and growing numbers of sexually transmitted infections (Monk, 1998; Hampshire and Lewis, 2004). On the one hand there is a view that sex education facilitates premature sexual activity, generates a reduction in social morality and removes childhood innocence. On the other

Abstract
Sex education is a highly emotive topic that generates strong social debate making this a very challenging area of health practice. This is particularly true with the education of primary school children. This study presents ndings from a qualitative study which explored the experiences of school nurses involved in teaching of sex and relationships education in the primary school setting. The ndings identify sources of tension in this area of practice and the strategies employed by the nurses to manage those tensions while operating within the context of existing organizational constraints. This provides the basis for consideration of what constitutes good practice. Key words Sex education Primary school

hand there is the view that sex education is a vital tool in promoting sexual health in young people, providing them with the skills and knowledge that can lead to safer sexual behaviour (Department for Education and Employment (DfEE), 2000; Hampshire and Lewis, 2004; Hampshire, 2005; Wilkinson et al, 2006). These strongly create tensions for those involved in the provision of this education that are likely to increase in the light of recent changes to policy which will make SRE compulsory in all schools in England. The media attention which has focused particularly on primary school teaching (Daily Mail, 2008) makes this a particularly challenging area for educators. School nursing practice in the UK includes a substantial public health roleincluding the promotion of sexual health (Croghan et al, 2003). This takes a variety of forms but often includes the conduct of SRE lessons. In the primary school this commonly involves teaching about puberty, conception and pregnancy; the content that is recommended for coverage before transition to secondary schooling (DfEE, 2000). Schools, however, have responsibility for delivery of the curriculum, and the decision as to who is involved in teaching this subject rests with the school. Involvement of the school nurse is therefore at the discretion of and by invitation of the school. Where school nurses are used there is evidence to suggest that they are valued by children and the school because they occupy the position of an outsider with specialist knowledge and skills to address a sensitive topic area (Cotton et al, 2000; Lightfoot and Bines, 2001). However, this outsider status requires school nurses to work with established school structures and personnel to deliver effective sex education. Managing the sensitivities around the issues of sex and young people in the education system is a crucial element to effective practice in this area. Given the social debate about sex, this can often be difficult. The literature on how practitioners experience and manage this situation is limitedparticularly on how nurses view the barriers to effective sex education practice in schools and also work to overcome them.

Hilary Piercy is Senior Lecturer, Faculty of Health and Wellbeing, Shefeld Hallam University, Collegiate Crescent Campus, Shefeld, S1 1WB Mark Hayter is Reader in Nursing, Centre for Health and Social Care Education and Service Development, School of Nursing and Midwifery, University of Shefeld, Samuel Fox House, Northern General Hospital, Herries Road, Shefeld, S5 7AU Email: h.piercy@shu.ac.uk

Aims and objectives

This study aimed to explore the experiences of school nurses involved in sex education in primary schools. It especially sought to address the following two research questions: What are the barriers that school nurses face when delivering sex education in primary schools? What constitutes good practice in terms of removing or managing these barriers?

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Methods
A qualitative research design was employed to capture an in-depth account of school nurses experiences. Qualitative research entails the collection of data that provide a detailed and rich account of individual and collective experiences and subsequently presents these experiences in a meaningful manner (Denzin and Lincoln, 2000). In this study it was important that nurses were encouraged to speak about their experiences of working in schools and delivering SRE to primary school-aged children. This study took place in 2006 in a school nursing service in the Midlands comprising 26 nurses serving 124 mixed-sex, multi-faith primary schools. Ethical approval for the study was granted by the local research ethics committee. Employing a purposive sampling technique all nurses in the team were invited to participate. A total of 16 school nurses took part in the study. All were female and of white European origin. The mean length of employment was 7 years and 6 months and their clinical experience of school nursing ranged from 2 months to 25 years. All the nurses had previous experience of conducting SRE lessons with primary school children. Three separate focus groups lasting between 6090 minutes were conducted. Groups were facilitated by two researchers, one acting as moderator and the other taking field notes. Each focus group consisted of five or six school nurses. A flexible interview schedule of open questions was devised, asking questions such as: Tell us about your experiences in conducting SRE in schools How do you think schools feel about SRE? Have you experienced and difficulties in your SRE role? Focus group discussions were digitally recorded and transcribed verbatim for analysis. A thematic analysis procedure was undertaken with the focus group data using the work of Aronson (1994) and Joffe and Yardley (2004) on qualitative data analysis. They describe how data can be initially combed and segments identified that represent particular issues, comments or experiences expressed by participants. These pieces of data are then given labels that reflect their meaning. As data analysis proceeds researchers look for patterns and links that enable these data segments to be placed in larger themes that enable a logical picture of the main elements of the phenomena under investigation to be presented in order to depict comprehensive pictures of the collective experience (Aronson, 1994: 21). as either facilitating or inhibiting the school nurses ability to make an effective contribution. Each of these themes will be explored separately illustrated with quotes from data obtained.

Building a relationship
As responsibility for delivery of SRE rests with the school, school nurse involvement is by invitation. Consequently the extent to which she was involved in teaching, her influence over lesson content and the amount of freedom she had in the classroom was dependent on the degree of trust that the school placed in the nurse. Continuity of staffing and the opportunity to develop a long-term relationship with the school were important in establishing and maintaining trust. Where the nurses had worked with the same school for a number of years, established relationships provided an opportunity for effective collaborative working in the planning and development phase resulting in a comprehensive programme with significant contributions by the nurse over several school years. The development of trusting relationships was undermined by reorganization and frequent staff changes. Where a school had experienced difficulties previously with staff changes, it created uncertainties about the extent to which they could rely on the nurse to contribute to the programme from one year to the next. This affected the incoming nurse when she was attempting to forge a relationship with that school. Because theyll usually ask you that, I get that asked quite a lot of times: Oh well are you here to stay now then or are you just here for this year? You know I think sometimes theyre a bit wary and well do we let her come in and do these things to probably never see her again. For incoming nurses, the schools attitude to them and willingness to involve them in sex education programmes was also influenced by the historical legacy that preceded them. This could be advantageous if the predecessor had had a good relationship with the school although in other circumstances this legacy had proved problematic. Sex education is a sensitive and carefully sanctioned aspect of the curriculum. If an outside agency is considered to have overstepped the mark in terms of the depth or breadth of material covered and transgressed school and parental expectations, the ramifications may be far reaching as one respondent explained: The school may only have one bad experience, not necessarily from us, and they back off immediately. It didnt work, we didnt like it, it was inappropriate and its like were not having anymore. I do have to question what interests have they got in those children but at the end of the day, we are only visitors.

Results
Three distinct but interrelated themes emerged from the data: Building a relationship Involvement in teaching Timing of delivery. In each of these themes a number of factors were identified

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Involvement in teaching
The nurses viewed involvement in SRE as an important and enjoyable part of their role describing it as the crme de la crme of their work. They saw it as providing opportunity to establish relationships with the children that could be built on in secondary education, and felt that they made a significant contribution to learning. While they acknowledged that schools could deliver effective SRE programmes without them, they considered that their input benefited the children: I think if the teacher was to suddenly sort of do it, Im not saying they wouldnt get the same information, they might do but I think you know the kids sort of see us something a bit more, somebody sort of special The nurses ideological belief was that they could and did use their specialist knowledge to make a difference. There are a number of ways in which they could do so, by: Advising on policy Contributing to curriculum development Providing training and support as well as teaching. The extent to which this had taken place was extremely varied. In a small number of cases, highly collaborative working practices with the school had resulted in the development of a comprehensive programme running over 3 school years within which the nurse had a significant defined contribution to each year. This concurred with their ideal model of SRE; as a thread running through the school curriculum with opportunity to incrementally build on knowledge year by year. The majority experience, however, was very different and largely confined to one or two lessons teaching children aged 1012 years about aspects of puberty and development before their transition to secondary education, the limitations of which were apparent. But what weve what were lacking is repeating it. You know, I mean, I think were still in that role of going in and doing the one-off. Going in on a designated day on a designated time, probably just for an hour or perhaps an afternoon, a couple of hours and talking about periods and growing up and thats it really. They also felt constrained in terms of the content of the lessons. There was an ever-present awareness among the nurses of a line that should not crossed; that their discussions with the children must remain within the boundaries of acceptability. Failure to do so was identified as detrimental, not only because it breached the agreement between nurse and school, but because of the possible and far-reaching ramifications for continued involvement and the effect of that on the children. Its what can happen afterwards, and that can change the whole emphasis then on what youre trying to deliver in the future. The position of that boundary, the specification of what constituted acceptable scope and detail of information was assumed rather than clearly explicated; it was described by one nurse as an unwritten agreement. Crossing that boundary threatened her continued involvement in this work. If you say something wrong, then theyll say, Well, we dont want you in again. The extent to which the nurses felt able to push on those boundaries in order to meet the perceived needs of the children was dependent on their relationship with the school and on their own level of experience and confidence. I dont know the school very well, they dont know me, so you err on the side of caution really. But the more experienced you are you do it and you perhaps take the consequences afterwards

Organization and timing

The nurses identified two organizational factors that affected their ability to contribute to SRE. Firstly, their own workload and secondly school decisions about when SRE was timetabled in the curriculum and the degree of nurse involvement. The school nurse role is complex and multifaceted. This places competing demands on her, which inevitably effects on her ability to contribute to classroom teaching of SRE. The availability of support staff, such as health care assistants, increased her ability to meet those competing demands. However, each of the school nurses was attached to approximately eight primary schools and the organizational decisions of each of them directly affected the school nurse. From the schools point of view, sex education needs to be accommodated in the overall school curriculum. This subject is traditionally taught in the summer term and this was the case in most of the schools that the nurses worked with. The basis for this is not clear and is likely to be multifactorial. It was proposed that this timetabling decision was influenced to some extent by the belief that the children are more receptive to this subject at the end of the school year because they are older. However, the timing of statutory assessments was also identified as a key determining factor such that SRE is commonly referred to as Sex after SATS. This caused problems for the nurses who found it difficult to honour teaching commitments to all their schools as well as fulfilling their other work commitments. The greater their involvement in each school, the greater the resultant difficulty: I actually deliver three sessions. So this is why

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um you know its very difficult to fit it all in the summer term because Im going in on three separate occasions for all of my schools apart from two. Several of them described how they attempted to manage this by being proactive and suggesting that the SRE be taught at other times in the school year. However, while the collective decisions of several schools clearly affects the nurse, for each of the schools, the decision is an individual one which is influenced by other factors that must be taken into consideration when planning a curriculum. Her ability to influence this decision and thereby better meet the demands of a group of schools was therefore limited. Im trying very hard to sort of say at the beginning of the year, when are you doing this and still in most schools you will get: Oh well we dont think were doing that until whenever. Can you just come in after SATs. Time constraints and competing workload priorities together with the timing of these sessions in the school curriculum placed the nurses in a somewhat paradoxical situation; a high level of involvement in the SRE programme for one school was only achievable if offset by low levels of involvement in other schools. The conflict between what the nurses considered to be the ideal and what was feasible for them to achieve was evident: In our patch I wouldnt be able to do that [provide a comprehensive package of SRE] because of the number of schools Ive got. I wouldnt be able to provide the ideal because I just wouldnt be able to do that. And if they dont ring me up and they say, Just drop the video off , thats quite useful to me sometimes and thats not ideal because Ive got too many schools to be able to go in and deliver what I want to deliver in every school. which justify her involvement in this work, however, they create an environment in which the children feel able to ask questions which challenge and overstep the boundaries of acceptability in a way that they would be unlikely to do with their classroom teacher (Piercy and Hayter, 2008). That risk is a core consideration for the nurses, one which influences their conduct of the lesson and thereby the extent to which their expertise and specialist knowledge is used. Drawing on organizational theory (Das and Teng, 2001), exploring that risk in relation to trust and control provides a useful theoretical framework in which to analyse the situation. The schools decision to involve the nurse in classroom teaching is founded on expectations; firstly the degree to which she can be depended on to deliver lessons and secondly that the conduct and content of those lessons will remain within the boundaries of acceptability and not incur repercussions. A number of personal and organizational variables serve to either strengthen or undermine this relationship. In relation to the conduct and content of the lessons, development of trust in this situation is dependent on the nature of the relationship between the nurse and the school. Sustained working relationships and previous positive experiences will enhance the development of trusting relationships. However, organizational changes that result in the nurses being reassigned to schools on a frequent basis, and therefore require that the school repeatedly forge relationships with new individuals, will serve to undermine that trust. These factors will also influence the extent to which a school feels able to trust that the nurse will turn up to teach these lessons. This in turn is influenced by the nurses belief in the value of their contribution to sex education which results in a high level of commitment to this work. However, the demands of a complex workload and the competing demands of schools who traditionally schedule this subject at the same time in the school year make it difficult for her to undertake this work and severely limits opportunities for expansion and development. Control has an acknowledged role in the conduct of strategic alliances constituting a process through which to reduce risk (Das and Teng, 2001). It constitutes the components of regulation and monitoringthe means by which one ensures that an activity is carried out according to plan. Control over the teaching content is realized in a number of ways. The school themselves are subject to external control, not only through established mechanisms such as OFSTED inspections but also from parents and other major stakeholders. When those schools elect to invite the nurse to undertake all or part of the teaching, they control the process to a variable degree through overt and covert surveillance (Hayter et al, 2008). It is the inter-relationship between trust and control that determines the nurses conduct in the classroom. Trusting relationships, established and sustained over time will diminish the schools perception of risk and

Discussion
The conduct of primary school sex education lessons by school nurses is problematized as a result of the attitudinal anxieties and organizational constraints in which it operates. The anxieties surrounding the content and conduct of sex educationin terms of what should be taught when and where the boundary lies between acceptable and unacceptableis reflective of the adversarial nature of sex education politics in England where media attention is never far away (Daily Mail, 2007; 2008). The lack of a clear boundary which has been identified by OFSTED (2007) as problematic makes the conduct of sex education lessons in the primary school a risky activity which is arguably made more risky when there is multiagency involvement. The nurses status as an outsider and her informal teaching style are key elements

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reflected in workload patterns, the school nurses ability to contribute effectively to the competing demands of individual schools will be further undermined. In this situation, it may be necessary to reconsider the nurses role in primary school SRE. BJSN Conflict of interest: None declared Acknowledgement: Thanks to Trudy Gregory and MarieTherese Massey who contributed to data collection, to the school nurses who participated in the study and their manager who made it possible.
Aronson J (1994) A Pragmatic View of Thematic Analysis. The Qualitative Report 2(1): Spring www.nova.edu/ssss/QR/BackIssues/ QR2-1/aronson.html (accessed 20 April 2009) Bleakley A, Hennessy M, Fishbein M (2006) Public opinion on sex education in US schools. Arch Pediatr Adolesc Med 160(11): 11516 Cotton L, Brazier J, Hall DMB et al (2000) School nursing: costs and benefits. J Adv Nurs 31(5): 106371 Croghan E, Johnson C, Aveyard P (2003) School nurses: Policies, working practices, roles and value perceptions. J Adv Nurs 47(4): 37785 Daily Mail (2007) Outcry over explicit sex education video shown to 5year-olds http://tinyurl.com/crxqgc (accessed 20 April 2009) Daily Mail (2008) Children to be given compulsory sex education from age four http://tinyurl.com/5qjv6b (accessed 20 April 2009) Das TK, Teng B-S (2001) Trust, Control and Risk in Strategic Alliances: An Integrated Framework. Organisational Studies 22(2): 25183 Denny G, Young M (2006) An evaluation of an abstinence-only sex education curriculum: An 18 month follow-up. J Sch Health 76(8): 41422 Denzin K, Lincoln YS (2000) The disciplines and practice of qualitative research. In: Denzin K, Lincoln YS, eds. Handbook of Qualitative Research. 2nd edn. Sage, London Department for Education and Employment (2000) Sex and Relationship Education and Guidance. Department for Education and Employment, Nottingham Hampshire J, Lewis J (2004) The ravages of permissiveness: sex education and the permissive society. Twentieth Century British History 15(3): 290312 Hampshire J (2005) The politics of School Sex Education Policy in England and Wales from the 1940s to the 1960s. Soc Hist Med 18(1): 87105 Hayter M, Piercy H, Massey M-T, Gregory T (2008) School nurses and sex education: Surveillance and disciplinary practices in primary schools in England. J Adv Nurs 61(3): 27381 Kirby D (2006) Comprehensive sex education: Strong public support and persuasive evidence of impact, but little funding. Arch Pediatr Adolesc Med 160(11): 11824 Kirby D, Laris BA, Rolleri LA (2007) Sex and HIV education programs: Their impact on sexual behaviours of young people throughout the world. J Adolesc Health 40(3): 20617 Joffe H, Yardley L (2004) Content and thematic analysis. In: Marks DF and Yardley L, eds. Research Methods for Clinical and Health Psychology. Sage, London Lightfoot J, Bines W (2001) Working to keep school children healthy: the complementary roles of school staff and school nurses. J Public Health Med 22(1): 7480 Lincoln YS, Guba E (2000) Paradigmatic controversies, contradictions and emerging confuences. In: Denzin K and Lincoln YS, eds. Handbook of Qualitative Research. 2nd edn. Sage, London Monk D (1998) Sex education and HIV/AIDS: Political conflict and legal resolution. Children and Society 12: 295305 OFSTED (2007)Time for change? Personal, social and health education. OFSTED, London Piercy H, Hayter M (2008) School nurse management of childrens questions when they are involved in primary school sex education: an exploratory study. Primary Health Care Research and Development 9: 7584 Wilkinson P, French R, Kane R et al (2006) Teenage conceptions, abortions, and births in England, 19942003, and the national teenage pregnancy strategy. Lancet 368(9550): 187986

Key Points
School nurses consider involvement in primary school SRE as an important and enjoyable part of their role The extent to which they can effectively contribute to the SRE curriculum is dependent upon development and maintenance of a trusting relationship between school and nurse Anxieties about overstepping the boundary of acceptability and organisational constraints serve to undermine their effective contribution

their imperative for control. They also provide facility for clearer definition of boundaries through the process of collaborative discussion. Conversely, a lack of trust and a high level of control both serve as constraints and diminish the scope of opportunity for the nurses to use their knowledge and expertise. Effective involvement of school nurses in primary school sex education is therefore dependent on organizational structures that foster the development and maintenance of relationships between school and nurse and provide the basis for meaningful communication about the operational aspects of delivering the SRE curriculum. The limitations of this study are that it relates to one geographical area of the country and represents the views and experiences of a relatively small number of practitioners. This should be considered in relation to the wider application of these findings.

Conclusions
School nurse involvement in teaching primary school SRE takes place within conditions that serve to control their involvement. The nurses employ a range of strategies in order to develop relationships of trust and thereby increase the effectiveness of their involvement, however, the extent to which they are able to do so is limited by organizational constraints. The recent introduction of compulsory PSHE of which SRE is an integral part in state schools is likely to place increasing demands on the school nurses. Unless this is adequately recognized and

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