DISCUSSION
This pilot study explored whether a training programme would improve school staff’s overall self-reported preparedeness in the management of the child with severe allergies. We moved beyond the focus of other studies (impact of training on school staff and confidence [16-18; 25; 26]), and assessed the head teacher’s response to policy review and implementation of preventative measures.
The fact that a number of trained schools, implemented an emergency management protocol for the first time following the training, confirms the value of training programmes in supporting schools with and without registered pupils with allergies (7).
A key element of the emergency management protocol is the storage and accessibility of the emergency medication (1). During the training, staff were encouraged to visit the emergency kit location to assess whether this was the most appropriate should an emergency arise. Post-training all schools had reviewed the accessibility of the emergency kit by staff.
Special supervision for children at high risk during meals is one of the fundamental recommendations for schools (1, 20, 21). As a minimum, young children with severe food allergies should be supervised by designated staff member(s) during mealtimes and also during indoor/outdoor activities (1, 20). This recommendation was adopted by a significant number of trained schools.
An area of practice which the majority of schools needed to review as a matter of urgency was the food consumption during pupils’ transfer. A ‘no eating policy on transport to and from school’ (unless medically necessary) was not in place. Schools seemed to respond to this call however further reinforcement is required.
Evidence suggests that the ‘no-nut’ policy does not offer additional protection as it has not been proven to reduce the antigen exposure. In addition, measures such as a general allergen-ban on their own are inefficient in preventing anaphylaxis as it is not possible to eliminate all allergenic foods from the school environment (21). Instead, holistic approaches to the management of allergies should be encouraged (1). Our training helped schools improve this holistic approach and they proceeded to review their ‘no-nut’ policy
Similarly, following training, schools reported that they had started providing pupils with teaching material and practical skills to self-manage their allergies. By engaging children as active participants in the management of their allergies, it is hoped that this may lead them to develop adaptive behavioural strategies in responsibility taking and self-management of their condition (22).
Trained schools also seemed to acknowledge the need for regular and specialised staff training in anaphylaxis. This correlated with the increased number of requests received by the local allergy services following training for further support. However school nurses, who would be the most suitable group of school staff to receive more specialised allergy training in mananging the needs of the severely allergic child, have been redeployed to other community posts (23).
Yearly training and practice drills for all school staff are recommended (1, 6, 21). We have previously reported that schools recognize that there is a lack of standardization in the management of the pupil with severe allergies and believe that a national policy along with support in implementing this are needed to enhance safety at school (7).
Several of the requirements for a safe school environment for children with allergies have been set out in detail in the recent published guidance from the Department of Education (6). However very little has been done to support schools in implementing these measures (19). We showed that schools require support, guidance, and regular training in order to feel confident in managing pupils with allergies. Several schools here reported willingness to implement additional measures to improve preparedness and agree with the generic provision of AAI.
The majority of the trained schools reported increased confidence and preparedness in dealing with the severely allergic child, even in pupils with no previous history of severe allergic reactions. Retention of knowledge and skills over time were not measured here. It has previously been reported that levels of self-rated confidence, preparedness, remain significant after 4-12 weeks follow ups (15) and decline 6 months after training (14, 24). A combination of yearly face-to-face training with online training after six months has been recommended before (6). A clear step by step ‘manual’ that guides school staff and offers troubleshooting if an issue arises along with face-to-face training for the implementation of an allergy policy and emergency protocol are required. This should be generated centrally and made available to all schools for implementation as mandatory. Schools should be able to prove their competency towards a safer environment for pupils with allergies; their performance in this area should be measured yearly and they should receive constructive feedback along with recommendations for those areas of practice that require improvement.
We acknowledge a number of limitations in this study. Due to the sample being small, not all of the areas tested post training reached statistical significance, however a general trend towards improving preparedness was observed. The results would have been strengthened by comparing the intervention group to a control group and by recording changes in self-reported preparedness over time to assess retention of knowledge. Lastly, it has been suggested that staff perceived confidence is a good indicator of the school preparedness in managing severe allergic reactions (25). However, self-reported confidence and preparedness may be an ineffective way of measuring actual preparedness on its own.