Introduction

The Norwegian Directorate of Health intends to establish a national programme to increase the competence of public health nurses, in order to follow up the Plan for the Improvement of Mental Health. In this study programme, public health nurses will improve their skills in preventing, identifying and taking action in situations involving mental and psychosocial problems in children and adolescents. The programme will also improve the students’ interdisciplinary cooperation skills.

The Norwegian Directorate of Health has given Diakonova University College the task of organising a post-graduate programme in mental health for public health nurses employed in health centres and the school health services. On the basis of the proposal, and in cooperation with Diakonova, the Directorate has selected subjects for a programme for post-graduate education which they hope will be made available at all of the university colleges in the country which offer nursing degrees. The health centres and school health services provide low-threshold services to children and their families. These services have a reputation for being easily accessible and non-stigmatising. The public health nurses are a fundamental part of efforts to prevent, identify and follow up psychosocial problems. They have contact with nearly 100% of all children, adolescents and their families. These services also have cooperative contact with other services in following up the mental and physical health of children and adolescents. In order to provide efficient, high-quality services, this professional group must possess relevant and up-to-date skills and knowledge.

Through its Plan for the Improvement of Mental Health, the government intends to revitalise its preventative psychosocial programme for children and adolescents. Early help and treatment are vital in this work, and the health centres and school health services will continue to be essential to these efforts. Initiatives to improve services such as early intervention, treatment and follow-up for children and adolescents will therefore receive higher priority.

In recent years, there has been greater focus and openness in society regarding mental health. At the same time, an increase in mental disorders has also been registered. Mental problems and disorders are a major public health issue that impacts deeply on individuals, families and local communities. A Norwegian Board of Health report shows that in many places the health services available to children and young people with mental illnesses are far from satisfactory. Support for families with children is important to prevent abnormal development, problems and psychiatric disorders in children. The health centres perform an important function identifying emerging problems in development and advising parents, and they may also refer clients to more specialised follow-up services. The school health services serve a similar function for schoolchildren.

A status report for the Plan for the Improvement states that signs of mental disorders that have been registered by health centres and school health services are not always referred to a doctor for medical examination. The report also found that cooperation between regular GPs and the health services is often poor. Preventive efforts seem to be fragmented, and there are unfulfilled needs among users. At the same time, it is an overarching goal of government’s children and youth policy to provide all children with equal opportunities and development opportunities, regardless of their social background and where in the country they live. The government therefore wishes to increase recruitment to, and reinforce psychosocial skills and knowledge, in health care centres and school health services.

Target Group and Admission Requirements

Public Health Nurse certification.

Aim of the Programme

1.2. Health promoting and preventative activities

Health promotion and prevention is based on two main strategies. The health promotion strategy is aimed at developing measures that can improve quality of life, well-being and skills for mastering the challenges and stresses that one is exposed to in everyday life. The preventive strategy is aimed at developing measures that can lead to a reduction in illnesses, injuries, social problems and mortality, and that may reduce risk factors. As a public health nurse one must deal with both strategies. This requires having both strong professional and practical knowledge, and also requires interdisciplinary cooperation.

Prevention is one of the priority areas in the Plan for Improvement. The preventative aspect of the health services for children and young people provides a unique opportunity for identifying vulnerable children and young people at an early stage.

With regard to the development of children and young people, deficiencies in services and the large potential inherent in the preventative services, the government wishes to strengthen the preventive health services available to children, adolescents and pregnant women.

1.3 Mental health

Mental health is a diverse concept and is interconnected with both physical health and the community around us. Biological, psychological and social factors help to shape the newborn child. Not least, children's families have a large influence. However, children with virtually identical backgrounds may develop completely differently. Some types of mental illnesses are hereditarily determined, but we also know that what happens in the first years of a child’s life can have a major impact on mental health. Factors such as secure attachments, good interaction, the feeling of mastering skills and a stable adult person who cares for the child, are just some of the conditions that determine the development of good mental health. The same concerns external factors such as friends, school and the child’s living situation.

Mental health is often perceived as an illness: anxiety, mania, eating disorders, inability to cope, etc. But it also has another dimension: “healthy” anxiety, exhaustion, joy, anger and frustration. This involves a wide range of emotions. To label normal fluctuations in a life as “illnesses” makes working within the field of mental health more difficult than necessary. There is great potential for health promotion work when you can help to change people’s attitudes regarding how we should understand and handle life’s difficulties. It is important to emphasise that children, youth and families always have their own resources, which are crucial with regards to the impact a psychological problem may have in practical everyday life situations.

Mental problems in children often manifest themselves in different ways than in adults, often through various forms of problem behaviour. Such behaviour can be generally described as externalising or internalising problems. Externalising problems often occurs among boys; problems which are turned outwards. Internalising problems is most common among girls; problems which are turned inwards, such as depression, anxiety and psycho-somatic disorders. Illnesses that manifest themselves at an early age, and which are related to various forms of neurological development disorders, are more common among boys. Girls predominate among the disorders that become evident during puberty, especially eating disorders and depression.

If one counts all the different types of mental disorders or disabilities in children and adolescents, then 15-20% of all children and young people in Norway have experienced such problems. Regarding the youngest, the 0-3 years group, however, there is little certain knowledge.

New figures from the Norwegian Institute of Public Health suggest that about 8% of Norwegian children have problems that are so serious that treatment is required. Between 0.4 and 5.7 percent of children have experienced a period of severe depression. A high degree of individual stability in psychological disorders has been shown. WHO expects an increase in psychological problems and disorders in the future.

The government’s strategy plan “... together on mental health ...” shows that even if it was possible to identify many vulnerable small children, we can only identify one third of 2-3 year-olds who would have developed serious problems by the time they reach 4 or 5 years of age. However, most children grow out of the problems if they are mild or moderate, while serious disorders may be more persistent.

1.4 The need for the development of competence
The first public health nursing diploma programme in Norway was started in 1947. Almost 60 years later, training is offered at eight different university colleges and bound together by a common curriculum. Within the national curriculum, individual institutions are free to put together the content for training programmes. Over the years, emphasis has been given in the various curricula to mental health. At the same time, society has changed and new issues and challenges have developed. When preparing the proposal, emphasis has been given to the fact that the continuing education programme is intended to be relevant both for public health nurses with many years of experience, as well as newly graduated public health nurses. This presents a great challenge. Basic knowledge of these topics mentioned above may be also be found in public health nurse study programme curricula.

Continuing education is important in order to acquire new skills and knowledge with regard to new research, and in relation to experience gained in different areas. The contents of the study programme will also examine issues in more depth than public health nursing study programmes, and thus provide greater ability to act in various situations.

Based on the national curriculum for public health nurse programmes, the public health nurse should, among other things, assess and positively affect the various factors that affect the health of the population. Moreover, she/he must consider children and young people’s physical and psychosocial development in an ecological perspective, and implement health promotion and preventative measures.

The Sintef report, STF78, concludes that users are very much satisfied with the care and services at health care centres and school health services, and by the school psychology services. However, parents’ experiences, and reports by young people involved, shows that users with mental health problems are less satisfied with the services than other users. The municipal agencies have improvement potential in terms of becoming more accessible, increasing their own expertise concerning psychosocial issues, providing more and better information about services available, increasing user participation, and improve coordination and cooperation with other service providers and agencies.

The National Council of Health Care Priorities has pointed out that cooperation between agencies concerning the care of children must be developed and strengthened significantly. The government also wishes to strengthen services, including health care centres and school health services, and to increase expertise in the area of violence in close relationships. There is also a need to increase knowledge concerning working methods and measures that can be implemented to prevent harm and help the child.

1.4.1 Mapping of health expertise within mental health
In 2003, the Norwegian Nurses Association, National Committee of Public Health Nurses, carried out a survey among its members. The survey, among other things, concerned which health issues the nurses faced in their daily work, and whether they had sufficient expertise to solve the problems they encountered. The survey showed, among other things, that the public health nurses felt that psychosocial problems were a fairly, or very common issue.

In 2006, the Norwegian Nurses Association, National Committee of Public Health Nurses, and the Norwegian Directorate of Health worked together on a new survey. It focused on the public health nurses’ views concerning their own competence and need for increased expertise in the area of mental health.

Preliminary data from focus groups in this survey shows that the public health nurses, among other things, wish:
• Increased knowledge of group management
• Increased knowledge of, and access to, practical tools, including screening instruments
• Methodological standards
• Increased competence in early identification
• Increased referral skills - i.e. better knowledge of the various services’ areas of expertise and competence - through better interdisciplinary cooperation.

The survey received responses from the 1064 public health nurses. The main findings showed that 20% of public health nurses experience that they only to a small degree, or not at all, possess expertise in relation to managing children and adolescents with psychiatric problems. Thirty-six per cent find that they to a small degree, or not at all, have expertise to deal with the children of mentally ill parents.
The table below shows the percentage of public health nurses that on the whole require to increase their expertise in the areas of:

Percentage: Topic:

46% Consultation techniques in relation to mentally ill parents
40% Early identification of mental health problems
35% Reviewing mental problems in children
35% Reviewing mental problems among youth
34% Family therapy
33% Sexual assault
33% Self-harm
32% Consultation technique in relation to young people
31% Behavioural issues
30% Melancholy / depression
29% Suicide Thoughts
28% Consultation techniques with children
27% Family problems
26% Use of individual plan as collaboration tool
26% Guiding parents / working with parents

Several themes were mentioned, common to the above is that more than one in four public health nurses questioned greatly required to increase expertise in the area.
With this background, the Diakonova University College has prepared a proposal for the curriculum for post-graduate programmes in mental health care for public health nurses employed in health care centres and school health services.

1.5 Aims
The White Paper 41 (1987-88) confirms that continuous education in health and social care subjects explicitly has the following objectives:
To secure the individual student’s skills
To provide health and social skills in line with new needs and objectives
It is pointed out that the continuing education programme should emphasise interdisciplinary aspects, user-perspective and user-participation.
The continuing education programme in mental health for public health nurses should have the following aims:

“The purpose of the competence-building programme is that public health nurses complete continuing education programmes and gain skills in preventing, identifying and intervening in the case of mental and psychosocial problems in children and youth, and to be able to interact with the physician and psychologist services in the municipality and the mental healthcare for children and young people.” (Specification of requirements regarding the undertaking, Directorate of Health.)

1.6 Teaching
The study programme consists of 3 courses. Each module has a duration of 4 days. They can be taken independently of each other. The workshops are planned for the following weeks: Week 45 in 2008, weeks 2 and 11 in 2009.
Theory and empirical data will be concretised using casework and review and discussion groups. Students are thus actively involved in the study programme, and the participants’ own experiences are discussed in relation to the programme content.

1.7 Programme requirements

It is recommended that each module requires ca. 500 pages of syllabus texts. Diakonova University College recommends that university colleges seek the relevant articles from journals and other publications, but there should also be room for texts from books on the subject. The programme literature should be in English and the Scandinavian languages.

It is expected that the student submits a reflection note of max. 1500 words on each module. The students should refer to the lectures and reading literature in the notes. Students will not receive feedback on the reflection notes.

Examinations will not be held with regard to the modules. The modules will be assessed as passed (and ECTS credits awarded), when the nurse has been present every day, read the programme literature and submitted a reflection note with references to the aforementioned specifications.
Most of the journals within the field of health use the Vancouver system as a reference system. It is recommended that the students also use this system.

1.8 Overview of modules
Basic Modules
1. Infants, young children and mental health
2. Schoolchildren and mental health
3. Children at risk of developing behavioural problems
Training in the use of different mapping tools and methods of work, interaction regarding early intervention, and procedures and tools that aid support by identifying and intervening will be included in each module related to the focus theme.

1.9 Admission criteria
To gain admission to the study programme applicants must be certified public health nurses.
It is possible to apply for exemption from some modules if the public health nurse has completed similar modules previously. Assessment of previous training and / or waivers will be granted by the individual university colleges.

2.0 SUBJECT CONTENT

It is emphasised that this is a proposal with regards to the content of the study programme. The programme should be a dynamic one. New issues should be considered incorporated in the modules as needed. Similarly, the literature list is not fixed. Diakonova University College has proposed recommended literature. Each university college must, in cooperation with lecturers, supplement the literature list at a similar academic level as this proposal.

Overlap of issues is also important which each university college must take into consideration in the selection of modules. The plan has attempted to avoid too much overlapping. However, some topics will be relevant in several contexts.

The content of the modules is based on the above-mentioned survey, the wishes of the Directorate of Health, the experiences of Diakonova University College and the recommendations of the reference group of the appurtenant institutions.

2.1 Goals for the continuing education programme
The continuing education programme is intended as a professional continuation of the public health nurse study programmes. After completing the study programme, the public health nurse will have knowledge of new tools to use in health care centres’ and school health services’ work. The programme will provide the public health nurse with greater readiness to take action. She/he will also have gained knowledge of current research of the appropriate fields.

Motivation to work in the professional area and with self-confidence as a professional will be strengthened.

2.2 The modules of the programme
Module 1
Infants, young children and mental health
Major social changes have led to changed conditions for children's upbringing. The child, family and family support now have to deal with a more complex reality than just a few years back. According to the Sintef report, the public health nurses are also concerned that the many psychosocial problems are largely a result of social conditions. In a primary prevention perspective, it is important to identify risk factors of a child’s formative environment. In this context, a parent’s illness is also relevant. Children who grow up with a mentally ill mother or father also have a high risk of developing mental problems.

The National Council for Priorities in Health Care propose that early intervention in mental health cases for children should be a priority. This means both identifying those children who risk developing mental problems and behavioural problems and to facilitate the appropriate treatment.

The relationship between children and close carers is of crucial importance for a child's physical, emotional, intellectual and social development. Early communication and interaction are essential for secure attachments, which in turn is a cornerstone of good interaction.

The interaction a child experiences in the first years of its life also provides the basis for its expectations towards others. Early interaction between child and adult has implications for how the child will later see and understand the world around it. Too many negative emotions during early childhood may affect the relationship the child has to its caregivers, and follow the relationship over the years.

Aims:
On completing the study programme, the public health nurse will have gained greater expertise concerning the interaction between the child and the caregivers. She/he will have gained knowledge concerning the importance of good interaction and the development of interaction in the family. She/he will have gained knowledge of observation, monitoring and intervention in the case of poor interaction. The public health nurse will also have acquired more knowledge about risk groups, protective factors, resilience and development aspects.

Module 2
Schoolchildren and mental health
Figures from Samdata show that 3.6% of children and young people under 18 received attention from the mental health services in 2004. A Norwegian study shows that 6.5% of children aged 7-9 years, have a need of specialised psychiatric / psychological help. The school health services have been in contact with many of these children.

Mental problems can have serious consequences for children and young people’s wellbeing and development. The problems can impair their relationship with parents and peers and gain crucial importance for their adaptation to school. Results from larger studies of children over a long period of time suggests that serious difficulties in pre-school age have a high stability rate; between 40 and 60 percent of the children with considerable problems at three-four years old, still had such problems at ten.

The public health nurse faces many challenges in her work with children. Not all children and young people have the words to express themselves, or an understanding of the added challenges they face. An important tool in the school health service is to be able to talk with children and young people. The public health nurse must also have knowledge of how she/he should be able to make contact with important partners in the work concerning the services offered users. The module will emphasise that as part of primary health care, it is the health care centres and school health services’ task to prevent mental and physical problems in children and adolescents.

Aims:
The public health nurse will be updated on psychiatric disorders among children. She/he will also have been introduced to recent research within the field of social problems such as bullying. In a society where a growing number of children have experienced crisis and trauma, the public health nurse will have increased her/his ability to act in this area. She/he will have acquired new methods in consultations with children and will quickly involve partners if needed.

Module 3
Children at risk of developing behavioural problems
A survey report of the methods and instruments used to detect children with a high risk of development problems, in the age group 0-6 years, shows that knowledge concerning methods in this area needs to be developed. The survey of the conditions in Norway concerning this area indicates that several different methods are used. Regional variation is great: competence of the health centres varies, and there are indications that arbitrary factors determine the choice of methods. There is international consensus that existing methods do not meet the current criteria for analysis tools for population screening. The report suggests more research should be done in the area.

The National Council for Priorities in Health Care believe that children and young people’s mental health must be more clearly prioritised in practice, because the suffering is severe, affecting many people and can have long lasting consequences. The health services must have a stronger focus on psychosocial factors in their work with children and their families.

A Norwegian study supports the assumption that it is possible to identify behavioural problems in young children. The results also indicate that it is possible to identify risk factors in a child’s formative environment that may result in persistent problems, when the child is as young as 1½ years. Identification of developmental and behavioural disorders in small children is generally considered to be important in the prevention of later difficulties.

Aims:
The public health nurse should be able to group cases into children with slight, moderate and severe behavioural problems, oppositional defiant disorder, and behavioural problems. Moreover, she/he will have achieved increased knowledge about how to analyse and review children with behavioural problems. In this connection, the public health nurse will have developed knowledge of different development paths and actions required in the case of behavioural problems.

Curriculum and structure

Minor adjustments may occur during the academic year, subject to the decision of the Dean