Process evaluation results

This chapter presents the results of the mixed-methods process evaluation. It begins by reporting how well the intervention was implemented in terms of the training components and the peer support service. This is followed by exploration of the extent to which the mechanisms of change in the logic model were activated, evidence of harm, and the extent of contamination and differentiation from usual practice. Evidence regarding acceptability of the intervention is woven through these sections, as it was integral to understanding implementation and the extent to which the mechanisms of change were activated. The chapter ends with a brief consideration of sustainability, although in the light of the null findings it is unlikely that schools or funders will be looking to roll out the intervention. In quotations throughout this chapter, P[n] indicates which participant is talking and Q indicates that the researcher is talking.

Implementation

Implementation of Wellbeing in Secondary Education training components

To measure the reach and dosage of the MHFA training, the number of teachers and other school staff attending and completing the courses were recorded. Reach of the 1-hour awareness raising course was measured by recording the number of staff that attended it; however, we could not identify how many of these staff were teachers and how many were other staff, such as teaching assistants or learning mentors. Fidelity to the training delivery plan and quality of the training was measured drawing on the training observations, checklists and evaluation forms completed by training attendees, and trainer interviews (see Chapter 2 for the description of these data sources). Response rates to the checklists and feedback forms were high (Table 30).

Dose

In eight (66.7%) of the 12 intervention schools, the prespecified intervention dose for the 2-day MHFA training (i.e. at least 8% of school staff attending the course and becoming a peer supporter) was achieved. One additional staff member would need to have been trained in each of the remaining four schools to reach that prespecified dose. In nine (75.0%) of the intervention schools, the prespecified 8% of teachers attended the 1-day MHFA for schools and colleges training. Of the three schools not reaching this prespecified dose, an average of two additional teachers would need to have been trained to do so. Reasons for schools not achieving the prespecified dose included researcher error, nominated staff being unable to attend at the last minute and trained staff leaving the school shortly after training and therefore not becoming peer supporters. Of all those trained, 92 (81.4%) peer supporters were still employed by the schools at T2.

Reach of training

Across the 12 schools assigned to the intervention arm, 113 teachers and support staff attended and completed the 2-day standard MHFA training, and 146 teachers and support staff completed the 1-day MHFA for schools and colleges training. A total of 666 (54.5%) teachers and other school staff attended the 1-hour awareness-raising session.

Fidelity to training components and adaptations

In all four of the case study intervention schools, observers assessed that the fidelity of training delivery was consistently high for each of the items of assessment (i.e. instructor knowledge of materials, presentation skills, facilitation and support of the learning, interest from the group and coverage of materials). There was little variation in mean scores on these items for the 1-day MHFA for schools and colleges [range 3.9–4.3 (out of 5)] or the 2-day standard MHFA training (range 4.1–4.4), although mean scores were slightly lower for the 1-hour mental health awareness raising session (range 3.4–4.1) (Table 31).

Turning to the participant checklists, most attendees scored trainers highly for knowledge of materials, presentation skills, diversity of learning materials, communication skills, use of a range of teaching approaches and ability to keep the course focused and relevant. There was little variation in the mean scores for each of the instructor qualities for the 1-day MHFA for schools and colleges (range 4.6–4.7) and 2-day standard MHFA (range 4.6–4.7) training courses (Table 32).

Despite their diversity in relation to their experience of delivering MHFA sessions, all six trainers interviewed reported high levels of fidelity in terms of ensuring key content was delivered:

No, we didn’t leave bits, we didn’t leave bits out, we had the time for each section we did . . . Yes, trying to think it through, to see where we’ve got, like if it said, optional to show a film clip, then we didn’t show it.

I have to make sure that I cover all of those slides that are in there. The only kind of flexibility that there is, is that sometimes there are up to three different videos, which talk about the same subject.

But yes, as far as the content and delivering the course was concerned, obviously, that was sort of, you know, drummed into us how important it was to sort of stick to it, so that’s what we did. But it was just little bits here and there and we thought, right, if we can just, rather than about 15 minutes for that activity, we’ll probably get it done in 10, so then we’d got actually 5 minutes to play with, you know, different things like that, but not much. We stuck to pretty much what it told us to do, you know.

However, three main factors appeared to present a challenge to that fidelity, requiring trainers to be flexible in course delivery, while still ensuring all key content was covered.

Needs of the group

Trainers discussed the need to re-evaluate choice of materials or ordering of exercises as the course went along, depending on the needs of the group or the dynamics that they had picked up:

You’re not meant to go off the planned route really but I just think, if the room is slumping slightly, you know, if you can kind of get them sort of re-energised for a little while and get them involved in something.

I think it’s a general thing about watching your group, seeing how they’re interacting, and making sure that they are interacting about the subject matter.

Location of the mental health first aid training delivery

Having the training on-site for most of the schools resulted in interruptions to the delivery in some cases, due to competing priorities of school staff (such as resolving student incidents), performance management meetings and break duties:

There was an incident in the school that afternoon, which required several members of staff to have to leave in the afternoon and go and do things and come back. I guess that’s just the nature of life inside a school.

Frequently I was having to move the day around or rejig, to make sure they covered the most important points.

In the MHFA evaluation forms, participants had the opportunity to write open-ended comments about their experience of the training and a number of participants commented that having it off-site would have been better.

Scheduling mental health first aid training within the school timetable

The school timetable was the third factor that presented challenges to the trainers maintaining fidelity during training delivery. Some trainers reported a reduction in the time they were expecting to have, with set break and lunchtimes and other scheduled school events being prioritised:

We couldn’t start at eight thirty because it was an [in-service] day and the principal wanted staff to come and join the main assembly for a talk. So that pushed it beyond 9 o’clock.

We’re not going to be pedantic about time scales . . . we’ll just go with the flow of the school day and just stop and start when it, you know, sort of automatically fits.

When faced with the challenges outlined above, the trainers appeared adept at thinking on their feet and ensuring that they still covered the essentials, which demonstrates the importance of having trainers that are skilled at working flexibly when delivering mental health training to schools.

Quality of training component delivery

Overall mean scores for the MHFA evaluation sheets were generally high (see Table 31). For the 1-day MHFA for schools and colleges training, mean ratings ranged from 4.4 to 4.7, with the exception of the environment rating, which was slightly lower (4.1, SD 0.7). Mean scores for the 2-day standard MHFA course were also high (range 4.3–4.7), with lower scores again observed for environment (3.8, SD 0.9). In the open-ended text space on the evaluation sheets, there were a few suggestions for improvement, including spending less time on the more serious but less common mental disorders, allowing more time for the course and changing the venue. However, the comments were overwhelmingly positive regarding the value and quality of the training, indicating a high level of acceptability for this part of the intervention:

This is the most interesting and engaging training I’ve had in years. One instructor talking all day and holding the audience? Amazing!

Longer would have been amazing but the instructor tackled some very complex and challenging topics with care and huge knowledge.

This course has been useful. I feel that all staff could benefit from the training to enable a whole-school approach.

. . . despite the topics being ‘dark’, I found the course really informative and interesting. I feel more confident at helping and supporting colleagues now, so thank you.

For the 1-hour awareness raising session, 85% of attendees rated the overall delivery of this session to be good or very good on the evaluation sheets, again, indicating good acceptability. In the free-text section, comments were generally positive, with words such as ‘enjoyable’, ‘interesting’, ‘informative’ and ‘useful’ being used. However, there were some observations that the session needed to be more interactive, to focus less on statistics and more on strategies, and to not be delivered at the end of the school day. In addition, two participants noted that staff should have been warned about the content, as it could have been difficult for some of them. There was also confusion from some participants about the MHFA training, suggesting that the intention to explain the study had not always worked well.

Overall, there were no discernible patterns of difference in dose, fidelity or quality of training between England and Wales, despite the different models of delivery used. This suggests that newly qualified and more experienced MHFA trainers delivered very similar training experiences, and that there were no systematic overall context differences by country that interacted with training implementation.

Implementation: peer support service

Reach of the peer support service was assessed using information from the teacher questionnaires regarding use of the peer support service, the peer supporter logs recording support given and peer supporter focus group data. As described in Chapter 2, all peer supporters were asked to complete an electronic log each academic term (three times a year). Of the 113 peer supporters trained, an average of 60.6 (53.6%) peer supporters completed logs at each of the five time points, and each supporter completed a mean of 3.1 (SD 1.5) logs. Just over half the peer supporters completed the log at each of the five time points, although 14.5% did not complete one at any time point.

Fidelity of the peer support service delivery was assessed through the peer supporter feedback meetings (described in Chapter 2). A feedback meeting was successfully held in all 12 intervention schools at 6 months, but was held in only 10 schools at the 18-month follow-up, despite multiple attempts to organise this in all the schools.

Reach of peer support service

At T1, 34 (6.1%) of 557 teachers indicated that they had accessed the peer support service in the previous 12 months. Of those teachers, most indicated they had used the service once or twice (n = 16, 47.1%) or once a term (n = 9, 26.5%). At T2, a similarly small proportion (n = 30, 5.9%) of the 510 teachers indicated that they had accessed the peer support service in the previous 12 months (Table 33). Of those who did use the service a large majority reported that it helped them.

Across all time points combined, peer supporters reported that they had supported a mean of 1.7 (SD 1.8) colleagues in the previous 2 weeks, of which, on average, 0.7 (SD 0.8) were judged to be in addition to colleagues whom they may have supported prior to being trained. In fact, in the feedback meetings and focus groups, it was clear that peer supporters found it difficult to distinguish what were additional episodes of support, partly because of the informal way in which support was often given within existing relationships:

So I don’t think it’s a matter of showing them the list [of peer supporters] and going, oh, so and so, I’ll just go and have a chat with him. It’s much more of an organic process than that, where certain people will come, and not necessarily in the context of school, just odd times. It can be a conversation will strike up at an odd moment and it will lead to some sort of offloading of some issue.

It is possible that those receiving support had a similar difficulty in deciding when something would be ‘counted’ as support given, which may partly explain why there was a discrepancy between the amount of support reported by the peer supporters and the number of teachers reporting receiving such support.

Most often, the support reported in the logs was provided to each person once [the mean number of colleagues at each time point helped once was 23.8 (40.8%) and helped twice was 18.8 (32.2%)]. Just over half (53.1%) of those supported were teaching staff. Support was most often provided during lunchtime (35.1% of help episodes) and problems were predominantly work related (50.9% of help episodes). Usually, peer supporters spent between 5 and 15 minutes assisting their colleague (42.1% of help episodes) and this was usually through face-to-face contact (42.4, 68.6%). The most common outcomes were no further action (39.5% of help episodes) or the peer supporter checking in with the colleague at a future agreed time (25.0% of help episodes) (Table 34).

Fidelity to peer support model and adaptations

At the first peer supporter feedback meetings, nine of the groups indicated that support had already been provided to colleagues by peer supporters. Peer supporters at the majority of schools had met as a group to discuss the set-up of the staff peer service (n = 9), with a smaller number (n = 5) indicating that they had held regular update meetings since then. All schools had set up a ‘buddy’ system, although this was reported to be fairly informal in all but one school. Five of the schools had set up a confidentiality policy for the peer support service. All schools offered service users the choice of which peer supporter they contacted and senior leaders were perceived to have helped raise the profile of the peer support service in eight schools.

One or two schools considered creating a specific space and time when staff could access peer support because of the difficulties of finding such safe space on an ad hoc basis. However, this proved difficult, as one peer supporter reflected on later:

I mean when we first did it, there was talk about having like a drop in, and then we were going to kind of have a rota and do that. But, you know, people are just so busy that it’s hard to ask people to give up their free time.

All schools had used advertising to launch the peer support service. Methods most commonly used for this included posters provided by the research team and staff briefings, e-mails and posting information in staff pigeonholes were additional methods used in a few schools.

By the time of the second feedback meeting, conducted in 10 of the 12 intervention schools, none still met as a group; rather, participants said that they discussed any issues with other peer supporters informally, if needed. Three of the schools had re-advertised the service, by e-mail (n = 3), posters (n = 1) and through a staff newsletter (n = 1). At this second feedback meeting, peer supporters at only four schools indicated that they had senior leadership commitment. The need for better formal recognition of the peer supporter work was discussed in some of the case study school focus groups:

I think that maybe needs to be addressed because we want to have more of an impact. Then actually, we need to have that recognition, as to the role that we are playing. And perhaps sitting down with the head [head teacher] and, as a group of people, and actually, this is our plan, like how do you, how will you support us, kind of thing, because it is really important.

Again, there were no discernible differences by country in the extent to which the guidelines were followed. Looking at the implementation measures used in the exploratory CACE analysis described in Chapter 3, Subgroup and sensitivity analyses, the total implementation score for English schools was 29 and for Welsh schools it was 28, suggesting remarkably little difference in how well dose, reach and fidelity were met.

Summary

The different components of the WISE intervention (i.e. the three different training sessions and the setting up of a peer support service) were delivered in all of the intervention schools. Generally, the training was delivered as planned, although the specified dose was not reached in all schools and the trainers did experience challenges in the school context. The peer support services were variable in their fidelity to the guidelines, with a majority not writing a confidentiality policy or feeling supported by senior leadership in the longer term. The significance of these issues will be returned to in the following section.

Mechanisms of change

Having established that the intervention was delivered in all intervention schools, a key question asked within the process evaluation was did the intervention work as hypothesised within the logic model (see Figure 1)? In the following sections, we consider the evidence for each hypothesised mechanism of change within the logic model in turn.

Did teachers have access to support and advice?

As a peer support service was set up in each intervention school, all teachers did at least, in theory, have access to increased support and advice. However, as reported in Chapter 4, Reach of peer support service, the teacher questionnaire data indicated that only a small number of teachers actually accessed the peer support service. The questionnaire also asked those who had not used it why they had not accessed the service. At both time points, the most frequent reasons given were help was not needed, a preference for talking to other colleagues and a lack of knowledge about the service (Table 35). Other reasons mentioned by fewer participants were lack of time, having access to support elsewhere, not wanting to talk to the particular individuals involved, believing that it would not help and concerns about confidentiality.

In keeping with the results from the peer supporter logs reported in the previous section (see Table 34), comments from the peer supporter focus groups did indicate that some teachers were using the service:

I rate the project, I think it’s in the forefront of people’s minds to talk to you. The volume at which they’re talking to you and sharing, I think it’s had an impact.

Yes, and likewise, the staff room, as you said, is really good. Because I had a member of staff who came and sat and spoke to me about quite a difficult thing that was going on, and would come and sit by me every break to talk about, and really, you know, we got to know each other through that, just when she’d started to talk and felt comfortable. And it went on and I followed that process right through. And I think somebody just listening to you and empathising with you, is often really, really powerful, even though they’re going through the most awful situations. And I think that’s where actually, if there is that opportunity to have tea and cake, yes, it’s great, it’s just currently, I don’t think that that, there is any room for people to manoeuvre within that because of everything that’s going on. Hopefully, when we get to a good place, I think that would be a good thing to try and initiate, you know.

Furthermore, there was evidence that the 2-day standard MHFA training had improved the quality of support that those acting as peer supporters could provide because of a better awareness of mental health problems and how to respond:

Those high-end issues, the signs to look out for, the symptoms, you know, it’s certainly improved my awareness of lots of different areas.

And as you were doing the sessions you were kind of thinking, oh that conversation I had with that person the other day, that kind of needs to be followed up because of a reason or something like that.

I think it has changed my language which is a weird way of describing it because you can be supportive without suggesting and I have stopped necessarily suggesting and it is about – what do you think will help you, what do you think your next step is? It is about not trying to solve the problem and I think just the change in language has helped.

Participants also highlighted the limitations of the service and the potential difficulty of providing the initial support but then having nowhere to signpost the person on to:

The other thing is have you have got the services that help and support and help people to move on to access the right things. Sometimes the right thing is we have had a whinge and it has made me feel better but sometimes it is not enough and it is about making sure that they can access other things. I have had one person talk to me over a period of time about coming back after a long term absence and he still feels that actually people don’t look at him in the same way because of his issues. But he is struggling and he could do with extra support in terms of school but you can’t really do it as well as perhaps you would like to.

In addition, comments from both peer supporters (focus groups and logs) and other teacher focus groups identified similar barriers to using the peer support service as those identified in the teacher questionnaires (see Table 32). Lack of understanding about how to access support, a general concern about confidentiality, a preference for using other informal or formal supports and a lack of time for both those needing support and the peer supporters themselves were all raised:

I’d struggle to tell you who was involved in it or where to go.

I feel I’ve got people I can talk to about things and be honest about, especially my line manager.

Therefore, although teachers in the intervention schools did have access to a new form of advice and support and some made use of this, there were significant barriers to uptake that appeared to result in relatively few teachers consciously making use of the service.

Did teachers have increased insight into their own mental health and did mental health have a raised profile in schools?

There was evidence of increased mental health awareness and skills among those who had attended the MHFA training. The MHFA evaluation sheets showed improvements following the course in self-assessed personal confidence to help [change to mean scores: 2.8 (1-day MHFA for schools and colleges) and 3.7 (2-day standard MHFA); p < 0.001] and knowledge and understanding [change to mean scores: 3.1 (1-day MHFA for schools and colleges) and 4.1 (2-day standard MHFA); p < 0.001] (Table 36).

Many focus group participants who had attended both the 1-day MHFA for schools and colleges and the 2-day standard MHFA training courses discussed increased awareness of the need to look after themselves and how to do this, and also when to seek support. Some reflected that this was important to ensure that they were better equipped to support those around them:

I think you’re a bit more aware of like thinking about yourself, making sure you care about yourself. And that we have such roles that are so, like so demanding and there’s so many different things going on, just to make sure that you yourself are OK and you’re in the right place to support others, because otherwise you can’t. I think that’s, I took that away from it.

There’s so much pressure on you as teachers that I think having that awareness of the mental health training from a personal point of view, as well as being able to support each other as a staff is really important, because I think that if we are anxious and we are stressed, and we are finding it difficult to manage or to cope in some way, or we are experiencing mental health issues, then that does impact on the children as well. So having this training is important not only in the way we deal with the pupils, but the way we manage our jobs for ourselves. Because otherwise, if we let things get on top of us . . . It’s nice to know there are people we can talk to about it or there are things that we can do to try and think actually, I need to handle this situation better.

The majority of attendees of the 1-hour awareness raising session also reported a small increase in knowledge and understanding in relation to all the topics asked about (Table 37).

Some focus group participants perceived a greater openness to talking about mental health in their schools, although it was not always clear how much this was down to the WISE intervention or how much it was influenced by a perceived growing awareness in society:

It is definitely a conversation that we’re all having. Members of staff are not frightened of using the words and having the conversations. Children are more and more asking for help, and maybe that’s because they need help, maybe that’s because we’re raising awareness.

I think there’s a better understanding of mental health, certainly, amongst the students, and there’s a lot of work on that, in terms of the knowing what it is and perhaps recognising it. As I say, the next steps now are, can we prevent it, and that side of things. I think there’s certainly an increase in the awareness of it and it’s just much more open, isn’t it I think, not just in schools but nationally as well. So that helps and it’s in the media and things like that, like those case studies and examples to be able to use and talk about when you do . . .

The teacher questionnaires did not ask about openness to discussing mental health; however, as reported in Chapter 2, they did ask about perceptions regarding how much the school cares about teacher well-being, the quality of relationships among staff and how often participants had given help to a colleague in the past academic year. As Table 23 shows, there was no evidence of a difference in these ratings by study arm at T2. Therefore, it appears that there were no large improvements to the perceived culture around support in the intervention schools as a result of the intervention.

In the student focus groups, participants were asked whether or not there had been any changes in the way that teachers at their school talked about mental health and well-being, to try and capture any increased openness that the students were aware of. Across all case study schools, and regardless of study arm, students reported that little had changed from their perspective:

[Shaking heads.]

Did trained teachers have increased confidence and skills in supporting students?

As already shown in Table 35, the MHFA evaluation sheets showed an increase in self-assessed knowledge and confidence to help among those attending both the 1-day MHFA for schools and colleges and 2-day standard MHFA training courses. Focus group discussions indicated that teachers who had attended either course found that they had been able to provide better one-to-one support to students and were also able to raise their awareness about mental health and well-being (e.g. through using the materials at assemblies and tutor time). Aspects of the course that were particularly highlighted as having been used with students were methods for dealing with anxiety, the concept of the ‘stress bucket’ and being able to identify when a student might need further help:

Some of the techniques and things they talked about, especially with the anxiety I found really useful just coming up, especially with some of the change in this school in the past year it’s been quite unsettling to some of the pupils.

Using the stress bucket when supporting them [students] one to one, they really find that they can relate to that. That makes a lot of sense for them. So when they’re trying to articulate how they’re thinking and feeling and why they’re thinking and feeling that, when we refer to that, it just helps them, ‘ah yes, no, that’s exactly what I’m feeling.’ ‘I get that now’ . . .

I have used some of the training skills with a number of kids because I would say it is almost like you have opened a wound and the number of children who are now comfortable with saying – I have issues, has gone up I would say. They come and see us when they are feeling a little anxious or a little of this or a little of that rather than letting it build up and up until there is some sort of explosion. We are seeing kids who are willing to say – I can’t cope right now.

It’s easier to spot signs of people dealing with anxiety and depression. You can refer with a bit more confidence to the pastoral team, you pick up on the nuance I suppose of dealing with those people.

One teacher from an untrained teacher focus group commented that they were impressed by the skills they had seen in trained colleagues regarding panic attacks:

I’ve seen different members of staff deal with panic attacks. The ones who are trained are phenomenal, I have full admiration, I’m watching and I’m thinking wow, they’re keeping their composure, erm, taking away the emphasis and working on their breathing and that’s fantastic.

Some participants did not feel that the training had given them new knowledge or skills, but generally still felt that it had reinforced what they were already doing, which helped improve confidence:

I found it really useful, in terms of validating what you already do and knowing you’re doing it right, and giving me a bit more confidence as well really in having those conversations. And to know that you are sort of like using the right skills and kind of giving them the right tools, so that was quite nice to have that sort of confirmation.

Did teachers have trained colleagues to offer advice in supporting students?

Although there was good evidence that those who completed the training had improved skills and confidence, there was little evidence of this learning being shared or of untrained staff asking trained colleagues for advice on supporting students. Only one teacher mentioned being approached by another member of staff for advice in supporting a student and another described being more proactive in supporting colleagues:

I think it just makes you more aware of, for example I knew when I took a pupil back to a class and the teacher was really struggling, and I was really concerned. Then I checked back and said – I was really concerned are you OK? I think that member of staff was quite shocked that I had actually bothered to go and see him to make sure he was OK.

The lack of knowledge-sharing may be because of contextual barriers, for example the limited time in schools to share learning and failure to embed any learning in the wider school processes (something that is discussed further in Chapter 4, Contextual challenges to the Wellbeing in Secondary Education intervention).

Did staff and student relationships improve?

Both the teachers and students were asked about teacher–student relationships in the questionnaires. At baseline and T2, the vast majority of teachers in both study arms agreed that their school cares for student well-being and has good teacher–student relationships (Table 38). A similar majority in both study arms reported providing emotional support to a distressed student at least once a month, with this proportion increasing slightly at T2. At T2, there were no strong differences by study arm in these variables.

In the case study, school teachers talked about having good-quality relationships with students in both intervention and control schools, with no obvious differences by study arm and no comments indicating that the intervention had led to improved teacher–student relationships:

I think we’ve got pretty good relationships with most of the students in the school as well, and it’s the sort of nurturing culture that we’ve got here, where we do encourage pupils, if there is an issue, speak up. And I think they’re pretty comfortable in doing that, which I think is the first step towards finding out what the problem is, making that initial contact.

We’re there for anybody who wants us, we do our job, we listen, and we do our best to help anybody, really. And that’s adults or children, or the pupils, really. And I do feel like they feel comfortable coming to speak to us.

The logic model was based on the assumption that if teachers have improved support for their own mental health then they would feel better able to then maintain positive relationships with students, a logic endorsed by teachers in both intervention and control schools. Given the lack of improvement in overall teacher mental health following the intervention, it is perhaps not surprising if there is a lack of difference by study arm in the perceived quality of teacher–student relationships by the end of the study.

Turning to the students’ perspective, Table 39 shows that at T2 students in the control arm had more favourable perceptions of the quality of teacher–student relationships and whether or not teachers care about or listen to students than those in the intervention arm. Generally, perceptions had become more negative across both arms for these variables, but this change had been more pronounced among the intervention group. There were no large differences by arm regarding whether or not the school cares for student well-being, whether or not teachers are there when the student needs them and whether or not teachers are interested in the student.

In the student focus groups, observations regarding quality of teacher–student relationships were remarkably similar between study arms. Both groups reported that relationships tended to be variable, with good relationships dependent on the individual teachers and the qualities they exhibited:

I know some teachers will ask to see you at the end of the lesson and some do ask if you’re like alright, if you’ve been upset in the lesson . . . but it’s not like all teachers. It’s only like certain teachers you get along with.

Some students acknowledged that the quality of relationships is shaped by both parties, highlighting poor student behaviour towards teachers and also the way vicious circles are created:

Some of the students like are hard to handle . . . Like some of them just, they just always act up for no reason . . . It’s only sometimes now but when we were younger, it was more often . . . before, when we was in a class, there was the teacher and this kid went mental at her and she started crying.

Some students are really disrespectful, they’ll tell them to ‘f off’ and calling them the ‘c word.’ It’s disgusting the way they talk to them, and I feel bad for them in that sense because they can’t really do much, and they’re too soft on them I think. Fair enough they’ll call down on them and call the head [head teacher], they’ll exclude them for a couple of days for it, but I think there should be more in place for that, because it’s not acceptable.

I think it’s just whether you have a good relationship with your teacher or not, you have to have a good relationship to be able to work, like I don’t have a good relationship with him [maths teacher], I don’t like maths whatsoever. I do play up in maths I’ll admit that, because I don’t like him. If I had a better relationship with him, I think I’d do better.

Some students in both arms described extremely negative relationships with teachers and noted that this would put them off seeking help from a teacher:

. . . some teachers like, I don’t know, like if they’re like having a bad day . . . they’ll just shout at us for not getting it. And there was one teacher who called another student . . . I wasn’t in the lesson, but they called him a . . . douche or something like that.

My tutor scares me. No, like honestly, whatever he says, he actually scares me. Like I wouldn’t go to him whatsoever, he’d be the last person to go to.

In a number of discussions, students noted their belief that teachers cared much more about their academic performance than their well-being:

They just generally don’t listen to the students, like they don’t want to, I don’t know how to explain it, they just don’t want to listen. They only tell us, do your work and, you know, the negatives . . . They don’t care about anything else.

These perceptions of teachers’ priorities are likely to reflect the wider context in which teachers work, which is considered further in Chapter 4, Contextual challenges to the Wellbeing in Secondary Education intervention.

Did students receive improved mental health support?

Chapter 4, Summary presented evidence that trained staff had improved skills and confidence in supporting students. However, this did not appear to translate into more support being provided in the intervention schools relative to the control schools (see Table 38).

Similarly, results from the student questionnaire showed that the number of students asking a teacher for help with a personal problem and proportion of those students finding the teacher helpful were similar between study arms at T2 (Table 40). In both cases, just under half of all responding students had asked for help and a majority found the interaction helpful when they did.

For students in the intervention schools to be more likely to seek help from teachers, their perceptions regarding teachers as a good source of support would have needed to change. The student focus group data did not show any evidence of this, with a number of examples shared where students felt that appropriate and timely support had not been given:

I can probably count the amount of teachers that would help on like one hand really, because I don’t really feel like they do anything. Someone in this school . . . was very depressed . . . there was always this constant look on his face every single day, literally, screaming, I want someone to talk to, I want someone to help me . . . it took his best friend to run to him to actually talk to him, from helping him to stop something that he would have done. And instead, it was meant to really be a teacher’s job to really make him sit down and say, are you OK, do you need someone to talk to?

I think they could do better, in acknowledging the signs of it more. Cos’, like, I saw a year 7 girl who’s mum had to physically pick her up and carry her up the stairs, and this was like a month or two into term, if the teachers had noticed ‘why doesn’t she want to come into school’ before, then they could have avoided all of that. Like we were walking to lessons and all we could hear this girl screaming, I felt really bad.

Although some students were able to name staff or processes by which they could seek help, barriers to doing so were noted, which had similarities to the barriers teachers cited to using the peer support service:

I’d rather someone who, well who’s never been to the school and no one’s ever really seen because usually, if like a teacher that’s been here for a while decides to take up that job, it would kind of be, people would kind of get the wrong idea and expect, know what they’re going to say, if that teacher has a reputation of maybe shouting at a student. When they sat down there with that teacher, she’ll say, oh you can talk to me. They’ll say, oh obviously not, since, for what you’ve done in the past.

On the back of everybody, all the teacher’s badges they’ve got numbers and stuff for people but again the people that you’re meant to go to I don’t feel comfortable. There are people, other teachers that I’d feel comfortable going to but not the ones I’m meant to.

I wouldn’t talk to my teacher. I feel like they judge you and then they will tell their teacher friends.

That’s the thing with school I think there’s so many students I don’t think they can just focus on one that has probably the same thing that most students have, because with exams and everything, probably half of the school has like a mental issue, it’s just the way it is these days, most teenagers do.

On the other hand, there were positive comments made in both intervention and control groups indicating that it could be helpful to talk to teachers in school about mental health. In addition, students felt that they could do this confidentially. Sometimes that person was their tutor, but the most important criterion was that it was someone with whom the student felt that they had a good relationship:

Tutors tend to be like the most understanding and the one you trust the most. I mean, you know, we’ve done like the whole school, every morning you see them in school.

Was teacher stress related to supporting students alleviated?

As noted by students in Chapter 4, Did staff and student relationships improve?, one source of teacher stress is poor student behaviour; therefore, if support for students were strengthened by the intervention, leading to improved behaviour, then this may reduce this source of work-related stress for teachers. In addition, feeling better equipped to support students (through skills learnt on the training courses and having access to better support for themselves) may also reduce stress.

The teacher questionnaires did not ask specifically about stress relating to student support, but they did ask more generally about stress and satisfaction at work. As shown in Table 6, at baseline, a small majority of teachers were satisfied with their work, and just under half found their work very or extremely stressful. The results of the exploratory analysis comparing these outcomes by arm found no difference between intervention or control schools at follow-up (see Chapter 3, Table 23). Given that there was no strong evidence that support for students at the whole-school level had materially changed, and teacher well-being and mental health had not improved, it is unsurprising that stress or satisfaction levels had not improved in intervention schools.

In the focus groups, there was evidence that teachers found supporting students stressful. Staff talked about a perceived increase in problems among students, which might be expected to lead to increased stress among teachers:

If you’re a counsellor, you have no choice but after a certain amount of time to be supervised by another counsellor in terms of to offload, to clear your own mental health and likewise in the school environment, we’re never given that opportunity and I think especially with the heads of year or pastoral, he does, they can deal with a phenomenal amount of issues ranging from the trivial friendship, to suicidal. Now if it’s a Friday afternoon and they’ve dealt with, I know from experience . . . Friday afternoon they may deal with three suicide attempts, and then it’s right OK, go back to see the kids and off I go, and then all weekend, absolutely fixated on those three students, hoping that in the next 48 hours nothing happens and yet there’s no well-being for those members of staff to actually offload that on someone else, if you see what I mean.

It’s going to become a bigger and bigger and bigger issue in schools for staff and for students. And actually, staff being able to help students is going to become more important because we need students to be more resilient, because what they’re being asked to do is so much more difficult. It’s at a time when curriculums are being squeezed into subjects that are thought of as important and, therefore, you know, expressive arts, things like that, are being squeezed. Everything that’s written in the press. So, you know, I think it’s tough being a student between the ages of 11 and 18, it’s tough being a teacher.

Yes, and access to people like Off the Record [young person’s mental health charity, Bristol, UK] and stuff, I don’t think it’s that straightforward. I’ve had students that have self-harmed and their parents have tried to contact Off the Record, and there’s another one as well I think, at CAMHS, and they’ve heard nothing back from them. And that’s, I know that it’s, obviously, an organisation that’s voluntary but, you know, there’s only so much that I can talk to a child about that kind of stuff, and they do need some more expert help with that. And sometimes, I think, those organisations, people slip through the cracks I think, and that’s really unfair.

There was no indication from the data that the WISE intervention was effective in addressing this important source of stress.

Contextual challenges to the Wellbeing in Secondary Education intervention

In understanding why the mechanisms in the logic model had or had not been activated, it is important to consider the context in which the WISE intervention took place. Many of the focus group discussions and head teacher interviews in both intervention and control schools highlighted the difficult job that teachers do, and a perception that the profession is becoming more challenging. In addition to the stress caused by student behaviour and concern about student well-being discussed already, another key issue talked about was workload and the consequential impact on teachers’ mental health and well-being:

As times goes on I think people will always say the teaching is becoming more and more stressful I think if you look at lots of public service jobs whether that’s in health care or police or whatever. Resources are being cut, demands are going up, targets are being set left, right and centre. And it’s fair to say that people are finding it more and more difficult.

Yes, my first year of teaching felt, it was just like, at the end of the day, just like lying on the floor being like, I’ve just had so many battles today, and you don’t battle with anybody anymore. It’s like you put your head on the desk and you collect your pens and now you leave.

I think the sense of guilt in our job is massive. It’s like we’ve all been there before and dragged ourselves into work barely able to stand and I know for myself I’ve had one period of sickness since I’ve been in this school and that was literally, well my face was out here and there was no way I could come into school, but by the time I came back, the first person I met was like, oh my God, you’re back, thank God for that. You can’t go off on the sick again and I had that all day, because of the kids I work with, that sense of guilt is enormous.

Part of the workload pressure came from teachers being held accountable for students’ results and having to meet unrealistic student attainment targets, often without consideration of the broader context. Teachers were aware that this could be at the detriment of student well-being and offered an explanation as to why, as discussed above, students perceived teachers to be primarily concerned about their performance over and above their mental health:

I think perhaps in the sort of last 10 years or so there’s been an increase in how, yes, it’s not enough just to be a student and do your best. It’s about actually having this very, sometimes quite, well very challenging in many cases, facilitate unrealistically challenging targets to try and attain. And there’s not that wider appreciation of a particular student’s context that can be applied to that data to make it a bit more real. And I think that’s sometimes very, very difficult to balance off as a teacher as well because you’re kind of, I know this child is doing their best, they may well not get this particular grade, but I know that we’re doing all we can, they’re doing all they can, and yet, there’s that kind of relentless expectation to keep on pushing and keep on pushing. And it’s that danger, kind of being aspirational versus being unrealistically, or being unrealistic, isn’t it?

As described in this chapter, the WISE intervention had high acceptability in this context. The majority of participants who attended the training were enthusiastic about the MHFA training courses and their potential value. Most participants were also positive about the peer support service in principle. A number of head teachers reflected on the dynamism and enthusiasm displayed by training attendees following course completion:

Yes, I mean staff were really excited, they were really bubbly, they were really enthusiastic about it. And they’ve had a couple of meetings as a group of staff to talk about, right, we’ve done the training, it was brilliant, really useful, how are we going to impact on staff, as well as on students?

This high level of initial acceptability could be explained as schools having reached a ‘tipping point’, where they had become increasingly aware of the need to address staff mental health and well-being. A number of participants reflected that schools’ well-being agenda had historically focused on students, whereas the needs of school staff had remained largely invisible. For example, one teacher made this observation about the school’s pastoral support:

I’d like to have access to a counsellor as well. I mean I’ve actually, I’ve suffered from, I’m not ashamed to say, I’m diagnosed with depression, and I actually went to the school nurse and the school counsellor and said, is there any opportunity for me to have some counselling? They were like, oh you can phone this number or such and such, go and see your GP [general practitioner]. But it was, no, you can’t come and talk to me, only the children can. I thought, that’s a shame.

The emergent prioritisation of staff well-being was not only because of its inherent value, but also because of a perceived link to teachers’ ability to undertake their professional role and mitigating the risk of burnout or absence:

I think the peer training that took place at the start of this term, to have staff in school who are accessible for other staff within school and not members of the leadership team I think gives us a far better conduit to deal with issues than perhaps otherwise would have been the case. It is about making sure that our staff feel valued really and if your staff feel valued, they tend to be happier, if there is such a thing. It can have an impact on staff absence and that, in turn, has an impact on outcomes. You know I don’t think we can divorce the two. We are an outcomes driven organisation but it is about ensuring that the workforce feel valued and if the workforce feels valued and supported, the likelihood is that they are more likely then to fulfil the goals of the organisation aren’t they.

There was specific acknowledgement of the current sociopolitical context of ‘austerity’ that schools were operating in, where sustained and increasing resource cuts were reducing the availability of external support (e.g. youth workers, educational psychologists). The WISE intervention was considered an innovative and necessary approach in strengthening teachers’ resilience so they could shoulder this extra burden:

I’m glad it’s being addressed because I think with services being cut and less options to have to refer students, I can see why they’re making, like putting it in schools because they’re kind of replacing services. And then one thing we do need is to have a replacement for it, so I think that’s really good.

. . . how schools move to up-skill staff now is absolutely vital in terms of what we’re talking about, in terms of the mental health, in terms of the well-being of students. Do you know what I mean? It is, you know . . . we’re not going to be able to employ, because we haven’t got the budget, a raft of educational psychologists. So it’s whether or not there are certain interventions or certain training schemes.

However, some participants reported what they felt was a tokenistic approach to teacher well-being and mental health, as opposed to genuine investment and commitment from senior leadership, with a few hinting that this may have been the approach taken to the WISE intervention:

The one thing I would say in this school context, is it has to be valued by senior management or it’s not going to go anywhere. Quite often things are tick-box exercises and they’re not committed to and they’re not evaluated and they’re not valued and there’s so many initiatives that they’re like, let’s have a go at this, let’s have a go at this. I would hate something as important as this, or potentially as important as this to just be, oh well there we are, we’ve just ticked another box. It’s got to be meaningful.

I think a lot of the things we do here is a bottom-up approach, rather than a top-down approach, so it is . . . the initiative is taken from staff and maybe for me, I think that should be more the role of leadership or management, and I don’t think that they are that proactive. It comes from the staff body, so it’s always a bottom up approach.

Perhaps not surprisingly in the light of such observations, a number of teachers discussed their frustration that the intervention had not become embedded in school life and ongoing processes:

There’s been no, we’ve talked about it again but there’s been, it hasn’t gone into kind of the whole-school ethos. So there’s been no time to reflect, no time to encourage me to look at like the ALGEE model or how I’ve used it. There’s been no, it hasn’t been linked to my performance management, you know, like it hasn’t gone into the ethos of the school, no time’s been given to it and it hasn’t been reflected on, so, therefore, it just seems like it was a thing we did just for doing sake.

Senior leadership were supportive initially but there has not been much interest from them since the set up. None of them have offered time or leniency with other duties to support the running of the peer support, or spoken to the team about uptake or usage.

Such comments indicated that, for at least some participants, the WISE intervention was seen as a minimally disruptive approach, a tick-box exercise rather than a serious attempt to address the structural determinants of teacher mental health and well-being. This may have diminished its acceptability over time, replacing initial enthusiasm with disappointment.

This failure to instigate meaningful change at the school level meant that the peer support service struggled to really take off, as peer supporters found it difficult to give it the time it needed. Furthermore, a number of participants described their school environment as characterised by a judgemental and punitive culture, which left them reluctant to admit any personal or professional challenges:

I don’t often like to admit when I’m struggling. I do feel in this job it’s a judge culture, and I don’t like to admit when I’m struggling and when I’m finding things really difficult, or difficult to complete, or whether I’m able to keep up on marking. So whilst it’s there, and as [P3] said, it does raise awareness. Again, I always have that in the back of my mind.

This directly impinged on intervention acceptability, manifesting in fears about whether or not the confidentiality of the peer support service could be retained:

I think it can be good. I think maybe in this instance there were too many. I also think it needs to be, I was a bit worried because when I look at that list, I see some of the biggest gossips in school on that list. And I worry, as a member of staff, if it’s meant to be confidential, how confidential would it be? So I would worry to approach some of the members of staff who are on that list. Now I, obviously, assume, in the training, that they probably would have been informed that this is a confidential service and that they should maintain confidentiality. But I think, when I see that list and I know some of the names on that list, I think, I don’t know if I want to go to that person and give out all of my concerns and issues about my mental health.

Summary

Although aspects of the logic model were achieved in the intervention schools (notably staff having access to support and advice, awareness of mental health and self-care being raised and trained staff having improved skills in supporting students), there was little evidence of whole-school change in terms of staff and students feeling more supported, and quality of teacher–student relationships improving. The WISE intervention was delivered against a challenging backdrop of staff feeling overwhelmed with workload and pressure to perform, a perceived lack of genuine care from senior leaders and a culture of fear, and there was little evidence that it had addressed any of these issues. Ultimately, these failures to instigate whole-school cultural change may explain why the intervention did not have a positive effect on the outcomes. They may also explain the finding that by T2, according to some measures, control school participants actually had a more positive view of their school culture relative to the intervention schools, because they had not had their expectations for change raised. The next section explores other possible iatrogenic effects of the intervention.

Unintended consequences and potential harms

Did the training cause harm to attendees?

As the training covered many of the common mental health issues and the training’s participatory nature, there was the potential for it to raise sensitive subjects for the participants. There were two comments from study team members during observed sessions that indicated one participant became upset from frustration at the lack of mental health services and another during the section focusing on suicide:

During the discussion around psychosis one participant became slightly upset at the lack of appropriate service available to support young people and the school. She gave a personal example when a young person exhibiting sign of psychosis was referred to inappropriate services and the negative impact on the young person and their family.

In 2-day observation, in one school [1D] a participant left during the section around suicide. One participant went out during one of the trainer’s anecdotes about suicide, upset – another participant followed them to check if OK. Participant then left for the day.

In these cases, the standard MHFA protocol was followed (i.e. trainers ask participants leaving the room to give a thumbs up if they are OK, otherwise the trainer checks with them whether or not they need further support).

No participants reported detrimental effects as a result of the training on the feedback forms. In fact, as noted in Chapter 4, Fidelity to training components and adaptations, the comments on these forms were overwhelmingly positive, in spite of what trainees acknowledged were difficult topics. During focus groups, a small number of participants reported that the training activated past experiences and issues for them, but they were not unduly distressed by this.

Did the peer support service cause harm to peer supporters?

In the peer supporter logs, there were a number of comments indicating that being a peer supporter could engender positive feelings of self-worth. Peer supporters did not record any major negative impacts (to themselves or users of the service), but there were a number of comments about the difficulties in finding time and space to provide support. There were also a smaller number of peer supporters who indicated feelings of powerlessness (when they did not feel that they could help or that anything would be changed in school) and upset (because of a very difficult problem or because they were experiencing something similar themselves):

Just the rushed nature of it; for example one discussion was when I was in the toilet! The colleague needed to talk so I ended up talking in there and had no break as a result. I didn’t mind but there seems to be no time to talk properly.

I felt a bit helpless as I could see this person was stressed. I spoke to them about practical issues and ways that they may cut the workload. However, they could not see the wood for the trees in this situation and it got worse. They are currently off work.

Emotional stress and worry for that individual you are concerned about, that come to see you. Lack of time to spend with staff and follow up.

Although a buddy system was recommended in the peer supporter guidelines, some peer supporters still commented on a lack of emotional support for themselves when carrying out the role:

Some staff were visibly upset when talking about the pressures that being a member of peer support staff puts upon them, especially when considering their own individual situations. The group expressed concern that with no support ‘above’ them in place (e.g. a counsellor, etc.) to offload upon then the role of PS [peer supporter] becomes very emotionally draining.

It’s an added difficulty when you’ve got a five-period day and suffer with mental health problems yourself. It can be a bit overwhelming. It got to the point where I had to avoid someone sometimes just to get a drink at break. It’s also stressful when a member of staff talks about self harm. While the school business manager has been very supportive, a number of HOD [heads of departments] under great pressure themselves have not been.

The intention was for peer supporters to receive ongoing support from HSCs (Wales) and CAMHS link workers (England). However, this did not happen because of the trained HSCs not covering the relevant schools in their day-to-day work and a lack of capacity among local CAMHS teams. If the intervention was to continue, finding a sustainable way for peer supporters to receive support would be important.

Did the peer support service cause harm to users?

Unfortunately, we were not able to interview users of the peer support service as planned, despite attempts to recruit through the peer supporters. In addition, through including direct requests in the teacher follow-up questionnaires, we received only one volunteer to take part. Therefore, no data were collected from the user point of view on benefits or harms of using the peer support service. As noted above, the peer supporters did not log any episodes of harm that they perceived had happened to users of the service as a result of taking part in the study, although the lack of time and also lack of safe spaces to provide support may have meant that the experience of using the peer support service had some negative consequences:

Yes. And it’s like that one where we got interrupted and it was really, that was the end of it that time. So I made a point of finding them early the next day and sort of saying, sorry, we were interrupted, you know, I’ve got some time now or we can arrange another time, sort of thing, because I didn’t, because I felt embarrassed by that, I have to say, because it was just like the moment had gone, so to speak. And I think it had taken them a bit of time to sort of build up to.

One person was so anxious about being seen talking to me by certain members of staff, we had to come up with a cover story so she could feel more relaxed to talk, and then find a remote space where she felt more comfortable talking.

One peer supporter described the negative consequence of a line manager suspecting support had been given, showing that concerns about confidentiality described earlier may have been justified in this school at least:

Possibly resulting from such concerns, the peer supporters in one school identified that since the formalisation of the support the informal supportive conversations had decreased:

They feel this may impact staff feelings re [regarding] confidentiality and they feel the more informal ‘how you doing’ conversations have decreased since introducing the service.

The formalising of support from members of staff, therefore, may have had the iatrogenic effect of making staff reluctant to approach them to talk about problems, which may have led to a less supportive environment within the school. However, there were no differences by study arm in perceptions of how much the school cared for teachers, or the extent of support given to or received by colleagues. Therefore, the data did not indicate colleagues becoming less supportive towards each other as a result of taking part in the study.

Programme differentiation and contamination

A final, important series of questions that we explored in the process evaluation were what ‘usual practice’ entailed, whether or not there was contamination in the control schools and what major events occurred during the study that may have interfered with the intervention.

The audits were intended to be the main data source with regard to these issues. However, there were some difficulties with their completion, with key contacts from the school not always being able to answer all of the questions without consulting their colleagues. Although we invited them to do this, or to put us in touch with other relevant informants, some data lacked completeness. In addition, some of the questions were open to interpretation and we were not always able to gather evidence to support responses. We completed an audit for all schools at baseline, as planned. However, at T2 we managed to collect audit data from only 18 of the schools, despite several attempts to contact the relevant staff members.

Usual practice in all schools at baseline

According to the audits, at baseline none of the schools had a specific well-being policy for students, only one had a policy for staff and another had a ‘stress at work’ policy included in their overall health and safety policy. However, most schools had some initiatives to improve staff and/or student well-being, with similar activities featuring in both study arms. For staff, these included mindfulness training, well-being groups, addressing workloads (e.g. new methods of marking), flexible working, regular social times to share food and drink and formal staff support (e.g. through line management and recognition of good work). For students, initiatives included pastoral care and extra support for vulnerable students, special assemblies promoting well-being and raising awareness of mental health, mindfulness lessons, peer mentoring, personal social health and economic education that covered well-being issues. One school had a pupil well-being group.

In the majority of the schools, informants reported that both students and staff had access to support services. For staff, this was mostly off-site via a range of providers and included occupational health, employee assistance programmes and local authority-funded support. For students, counsellors were generally available on site, either employed directly or working for local organisations. Several schools reported that these counsellors were available part-time only.

Did the control schools take up similar interventions to the Wellbeing in Secondary Education study during the study period?

There was no strong evidence in follow-up audits of a large increase in support for staff or students in the control schools. Data from the head teacher interviews and staff focus groups revealed a range of initiatives for staff and students that schools had recently implemented, although it was not always clear whether these had started before or after baseline measures were collected. Those that focused directly on students included mindfulness training for vulnerable students, a writing project for year 11 students (aged 15–16 years), activities to help students manage stress (including exam stress), student peer support and homework clubs. One school mentioned that they were co-operating with an external agency, ‘Kooth’ (London, UK), to provide online mental health support for students:

. . . we’ve got the Kooth pilot . . . which is happening, which has been launched with all our year 7/8/9/10 students at the moment.

Some schools described their recent activities to promote student well-being as being big developments:

The well-being facility is the new thing that we’ve got in this school, so we didn’t have it before and its being well used, it’s being well used that it’s a big, big development for us . . .

It’s increased quite considerably this year . . . we did a big push in terms of assemblies and so on. We had . . . the mental health nurse, talk about the issues surrounding mental health . . . We made the support mechanisms available to pupils and . . . increased the awareness . . .

There were also new initiatives to promote staff mental health and well-being, although these were smaller in number. Some schools had focused on well-being during in-service training days and some had introduced mindfulness training or activities such as yoga and sports. One had set up a well-being group for staff and conducted a well-being questionnaire to develop an action plan:

. . . there’s a few things that go on, as a result of that [in-service] day . . . it’s good that it’s on the agenda, because it wasn’t on the agenda for, I’ve been here 7 years and you’ve been here longer, and I’m pretty sure it wasn’t on the agenda up until last year, but there’s still quite a lot of work to do with it I think, it’s probably fair to say.

. . . our well-being group for staff has probably been new, we are about to look at the findings of our well-being survey and look at what we need to do and how the staff action plan related to that.

One head teacher reported that during the intervention period there had been a shift in the way that the school thought about staff mental health, resulting in greater consideration of teachers’ well-being with regard to workloads:

. . . what I would say is I think it’s been far more intrinsic. We’ve been thinking about staff mental health and well-being in a far more pro-active way, shall we say, in terms of when we’re introducing things, the work/life balance thing, in terms of what we’re expecting them to do.

The motivations for the implementation of the different student and staff initiatives by schools were not clear, apart from an apparent concern to improve well-being of students and staff in the school, which presumably had motivated the school to sign up to the WISE study.

Is the Wellbeing in Secondary Education intervention differentiable from ‘usual practice’?

As already noted, ‘usual practice’, as identified in the baseline audits, did entail some activities to support staff and student well-being/mental health. However, components of the WISE intervention were quite different from the usual practice reported by schools. Post-intervention audits in the intervention schools revealed some new activities, specifically the employment of a pastoral support officer to work with year 7 and 8 students (aged 11–13 years), a relaunch of the school council for students, focus on antibullying and the introduction of a student peer support service. Like the control schools, some head teachers reported changes that had been instigated recently and, in these cases, they explicitly put this down to participation in the WISE trial:

. . . during some of the initial [WISE] meetings, it transpired that well-being, because we had a pupil well-being group but it emerged that there was possibly a staff well-being issue. Issue is perhaps too strong a word but staff well-being perhaps as an area that wasn’t having enough overt focus as perhaps was needed.

We’re trying to do things, so for instance, we had the staff who were involved in the project [WISE], who’ve been trained, we’re now running drop-ins every day after school in the staff room. So there’s free tea and coffee available every day, there’s posters around the school saying, come along and have a chat . . .

. . . out of that group of people that have been trained to be peer mentors [through WISE], one of them came up and said, do you know what, we don’t do enough around staff voice. OK, great, what shall we do? Well could we have a drop box? So we do . . .

What major events occurred in each study arm?

In many of our study schools, major events and changes that had occurred during the course of the study were reported in the follow-up audit. Major events were described on the audit forms as things ‘that could have affected teacher and/or student well-being’. Of the 18 schools that provided data for the follow-up audit, 14 reported at least one major event or change (8/10 control schools and 6/8 intervention schools). The types of incidents are reported in Table 41.

Schools in both the control and intervention groups experienced some significant events that will have undoubtably had an impact on staff and student well-being. Schools in both groups experienced most of the issues, including student deaths, changes in management and staff, and changes to school premises and structure. However, there were some incidents that were reported in one arm only. In the control group, three schools reported staff deaths and one school reported two serious incidents where staff had to intervene to save the life of a student, whereas no such events were reported by intervention schools. In the intervention group, two schools reported negative feedback from the relevant inspectorate [Office for Standards in Education, Children's Services and Skills (Ofsted) or Estyn]. One school was given a ‘requires improvement’ assessment and another was placed in special measures. None of the schools in the control group reported negative assessments during the study period.

Summary of contamination and differentiation from usual practice

Although the audits indicated that ‘usual practice’ already entailed a certain amount of activity to support student and teacher mental health, this was broadly similar across both arms. The components of the WISE intervention were different from usual practice and the control schools did not introduce components similar to the intervention during the study period. There were a similar number of major events reported in both study arms, although there were a small number specific to one or other arm. The possible significance of this is considered in Chapter 5.

Sustainability of the intervention

The findings discussed in previous sections regarding the failure to embed the intervention into ongoing practice in schools raises questions about how sustainable the intervention would be. Among intervention funders, there were three issues regarded as important when considering likely sustainability. One was the extent to which the intervention aligned with the strategic priorities of their respective organisations, which may affect any future funding, but also the extent to which schools would be encouraged to take it up:

Yes, it fits well. So you’ll probably be aware that, well I mean we’ve already talked about the sort of strategic priorities that, you know, are in place. I guess we have also relaunched our healthy schools programme and the mental health badge, which enables schools to just focus on particularly mental health, so that they can really dedicate their time to that. It does include an element around the staff well-being. It does mention mental health first aid training within it. So I mean it’s very well aligned to that programme of work. And I’d say it’s fairly well aligned to the sort of new policy context and, you know, developing leads in schools around mental health and sort of teams around mental health.

. . . one because we recognised that mental health was a priority and looking at the school setting as a mean of looking at mental health outcomes, secondly, for us it was consistent with our ways of working in the sense that it was a whole-school model.

The second was the extent to which the intervention was found to be effective, in a context in which evidence-informed practice was often considered lacking:

My view would always be if we’ve got interventions that we believe we have an evidence base for and we believe have a cost effectiveness and they’re working on topics and health outcomes that are important in a policy and a population perspective, which this one would be, then it’s an easy ask to be honest.

The third factor was the need to develop an infrastructure so that any future training or rollout could genuinely stand alone, rather than rely on external support:

The way I would see it being sustainable would be that the various partners/agencies on the ground commit the resource. If everybody says OK we can give X number of days of so and so’s time in order to deliver this, then that helps to make it doable. Increasingly now that’s how you make things work. You provide the opportunity but on the ground people will come together in a coalition to deliver something under the auspices of one of their local partnerships.

However, even if these three requirements were met, concerns were still expressed by one of the funding representatives and some head teachers about difficulty finding the resources needed to ensure that the intervention became routinised, particularly in terms of providing future training to replenish peer supporters who may have left the school:

Well I think, unfortunately, the first question that any school would be asking at the moment, is one based around finance. So, you know, the commitment to the training, for example. So it depends how that’s funded, how that training is made available. I suppose the other resource cost then is the time that, the time pressure that it puts on colleagues, in terms of making themselves available.

Given the fact that the intervention was not found to be effective, it is unlikely that funders or schools would be interested in further exploration as to how to make the intervention sustainable.