On a windy day in Crestone, if you know just where to look, you can see tiers of Tibetan-like prayer flags fluttering atop one of the town's taller buildings. Alison Martinez knows where to look. She is a public health nurse at the East Kotney Health Unit. For her, the flags represent the voices of grade 8 girls rising over the town. She was there when the girls wrote messages they wanted to share with the world on the brightly coloured squares of fabric.

The flags are an encouraging symbol for Martinez and her colleagues who work with youth in the community of Crestone. She says, "As girls move through the school years, they often lose their voice and become silent." She describes a tendency for girls to drop their sense of self and to over-emphasize the opinions of others. It can lead to unhealthy behaviour that increases the risk of unwanted pregnancy, sexually transmitted disease (STD), eating disorders, substance abuse and/or depression.

A few years ago, Martinez and public health nurse colleague Mary Jean Searle felt they were missing the mark in health promotion for this age group. They had been doing 80-minute presentations to grades 8 through 11 on birth control, pregnancy and STDs. The students were interested, but there was little interaction and the public health nurses felt they were somehow not meeting students' needs. "We felt that there had to be a better way of doing it," says Martinez. "Students already had a lot of the information. It was more about, 'What do you do with the information?' and 'How do you make decisions for yourself?'"

An Alternative Approach

As they talked with others about alternative approaches to sexual health education, a teacher suggested, "Wouldn't it be cool to take these girls out on a retreat?" The idea came from Diane MacDonald who teaches the high school career and personal planning class. Martinez describes her as, "one of those teachers kids really connect with."

Martinez and Searle decided to take her idea and run with it. They applied for and received grant money from STD/AIDS Control. That left them with just six weeks of planning time before the good weather would change, thus making a camp-like retreat a tough sell with the students.

Martinez, Searle and MacDonald quickly brought youth alcohol and drug counselor Julie Miller on board and together they formed a planning group. There was no ready-made blueprint for planning a sexual health education retreat. However, the group members knew how to look for relevant information. Martinez and Searle demonstrated meeting Standard 2: Specialized Body of Knowledge in the RNABC Standards for Registered Nursing Practice in British Columbia. They applied Indicator 1: Knows how and where to find needed information to support the provision of safe, appropriate and ethical client care and Indicator 3: Interprets and uses current evidence from research and other credible sources to make practice decisions.

A literature search led to a manual entitled Girls in the 90s (Friedman, 1999). The book is a guide for teachers leading group discussions with girls in grades 6 and 7 on issues related to healthy eating, body image, self-esteem and coping with stress. While the content is aimed at a younger age group and was designed for a series of discussions rather than an overnight retreat, it helped the public health nurses to solidify a philosophical approach.

Martinez describes the approach this way: "If girls value themselves, if they are connected to each other, have accurate, comprehensive information and feel safe to speak up, they are likely to make good decisions."

This approach was in keeping with other literature that demonstrated that youth responded better to a broad base of information and a range of options rather than to one approach, such as abstinence.

Another source of information used in planning the retreat was the students themselves. An anonymous pre-survey asking girls what they find confusing and worrisome in their lives showed concerns regarding weight and body image to be the most predominant theme.

With this in mind, along with the experience and knowledge of an interdisciplinary group of professionals, an agenda was developed. Martinez says, "We wanted to create the idea that we were inviting the girls into the community of women. And part of how women get together is we eat well, laugh lots and talk about things."

Planning the Retreat

Activities were planned that were collaborative, active, reflective, creative, expressive, informative and just plain fun. They organized a collage-making event related to body image. They set themes for skits such as "it's my body," "you're feeling that way too?" and "we're all one." They scheduled to play a game called "Sexual Jeopardy" in which teams choose from questions in categories such as STDs, pregnancy and birth control. And they arranged for the prayer flags on which the girls would be invited to write their heartfelt messages to the world.

Another activity they prepared was a game called "Fishbowl" where six to eight participants (including a facilitator) sit in the centre of a large circle to brainstorm on an assigned question, such as "How many of your classmates are sexually active?" or "What percentage of B.C. teens have had sex by the age of 17?" or "How do you know when you are ready to have sex?" Meanwhile people on the outside of the circle listen.

"It's a good exercise," says Martinez, "because they get exposure to different opinions and learn that what is normal has a really broad range. That's important because a lot of teen activity is based on what they think everyone else is doing."

For dinner on the first night of the retreat, the girls were invited to dress "outrageously." Organizers presumed costumes would reflect a great deal of "primping and preening," but at the retreat they were surprised to see a creative display of diversity and self-expression.

What about food? A local grocery store provided a shopping discount and the planning group is fortunate that high school teacher Diane MacDonald has a passion for catering as well as teaching. MacDonald took the lead on meal planning and preparation. The idea was to surprise the students with food that was teenfriendly but prepared with a sense of caring and flair they might not expect. Martinez and her group wanted the girls to feel well looked after. They succeeded with snacks, such as nachos and smores (a graham wafer, marshmallow, chocolate concoction), a three-course sit down dinner, a dessert table piled high with cakes brimming with variations on whipped cream, lemon and cherries, and finally strawberries dipped in chocolate for a bedtime snack.

"The kids were blown away that someone would prepare food like that for them," says Martinez. "And their appetites were wonderfully healthy."

Raising the Profile

With meals looked after and the agenda set, the planning group still needed volunteers to help run the retreat. They targeted female youth leaders in the community and local health care providers to raise their profile with the students.

Says Martinez, "We thought, 'If they're rubbing shoulders with the physicians, the alcohol and drug counselors and the public health nurses, and seeing us as people in the community saying, 'Come and see us,' then they are more likely to come and see us."

In other words, it's a way of teaching about health care services. For registered nurses, introducing clients to relevant health care providers is part of Standard 5: Provision of Service in the Public Interest, Indicator 6: Assists clients to learn about the health care system and accessing appropriate health care services.

Standard 5 is also about collaborating with other members of the health care team in providing health services. This project came together through the efforts of an interdisciplinary planning team that invited the involvement of key community members. "A big part of this is the partnering and community spirit behind it," says Martinez. Support for the project was also provided by the local Eagles Club, the Inclusive Community Youth Project, the Crestone town council. Crestone Credit Union and the Interior Health Authority,

Also significant is who was not invited to participate in the retreat. Organizers wanted to create an atmosphere in which the girls felt safe to express themselves without fear of being judged. To help facilitate this, no guys or parents were invited, and female teachers were only involved in a limited capacity.

Safe and Ethical Care

Considerations of safety are addressed in RNABC's Standard 1: Responsibility and Accountability, Indicator 4: Takes action to promote the provision of safe, appropriate, and ethical care to clients, and in Standard 4: Code of Ethics, which upholds the value of "safe, competent and ethical care."

A safety message was also promoted in some of the planned activities. The girls were encouraged to develop a sense of looking out for and supporting one another. For example with the "Puzzle Exercise," each person receives a puzzle piece in an envelope. With one piece only, it is impossible to identify the picture. Gradually and in stages, the pieces fit together and a picture is formed.

"The point is that every piece of the puzzle is valuable and if we damage a piece of it we damage the picture for all of us," Martinez explains, "You never know where the help is going to come from. Maybe one of the girls is going to have information or a strategy that's going to help somebody when there's trouble at a bush party some night."

Six weeks of planning flew by and in the fall of 2003, just days before the retreat was to take place, the organizing group was ready with an agenda, transportation, accommodation, meal plans and adult volunteers "bursting to dress outrageously." But one critical component was missing. Out of a possible 70 grade 9 girls, only four had signed up and submitted consent forms. With a swift and determined promotion campaign targeted around the girls' physical education classes, the numbers rose to 35. The retreat was a go.

In fact it was a big success. Judging by the levels of enthusiasm at the retreat as well as by comments written in an evaluation, the girls had fun and learned at the same time. Comments included, "I learned about myself," "I learned about what other people think and feel" and "I learned it's better if we stick together." There were also requests for "more pictures for the Sexual Jeopardy game."

A similar retreat for grade 8 girls was offered the next spring. This time, 42 girls signed up with no arm-twisting. That was followed by a five-hour evening event for grade 11 girls and a full-day follow-up building on the previous retreats for grades 9 and 10. Once the grade 8 girls have had their retreat this spring, all the classes will have had at least one retreat offered to them.

Evaluation

After each retreat, the program is evaluated and adjusted accordingly for the next time. So as requested, more pictures have been introduced to "Sexual Jeopardy." "Graphic pictures are what they both love and hate about the game," says Martinez.

Peer facilitators have also been introduced after great success in a trial run. "They are so effective," says Martinez. "Something that adults might try to say (that doesn't sink in), becomes a great point of discussion when the peer facilitators act it out in a skit."

When registered nurses evaluate their approach and make appropriate changes, they are demonstrating Indicator 7: Evaluates client's response to interventions and revises the plan as necessary from Standard 3: Competent Application of Knowledge.

The public health nurses have also determined that they need some new resources to go with their birth control kit. During the retreat they invite the girls to look at the various contraceptive devices and ask questions. It's always a popular activity, but the public health nurses know what will make it even better. A local quilter is making a life-size anatomically correct doll complete with breasts, vagina, cervix and uterus. Martinez says, "Those who have seen it laugh and say it's funny and beautiful at the same time."

It's another example of the community spirit that has supported the retreats from the start and has helped Martinez and Searle to develop a more relevant health promotion program for high school girls.

"It's all about quality improvement," Martinez says, "and demonstrating respect and caring for the young girls in our community."

That takes us back to Standard 5. Provision of Service in the Public Interest, Indicator 4: Advocates and participates in changes to improve client care and nursing practice.