by Adria Pavletic, RN, MA, MN, NCSN, Director of Health Services

During the typical school day, the chief complaint of teenagers who present to the school nurse is often, ‘‘I don’t feel well”. The challenge to discover what is medically wrong beyond those words requires refined assessment skills, relevant clinical experience, perceptive listening skills, and the ability to create a welcoming atmosphere of trust, competence, and caring. Frequent school nurse visitors, especially those who report vague somatic complaints, require thorough and careful attention to help discover the need behind the visit. Somatic complaints, unsupported by objective measures, or inconsistent with physical findings, should prompt the school nurse to consider psychosocial and/or emotional origins for the expressed complaint.

School nurses, by nature of their availability, supportive role, and clinical expertise, are in a primary position to identify adolescents who are suffering from unmet psychoemotional concerns. The school nurse is accessible to every student with a door that is always open. Help is available without an appointment or even without the ability to clearly articulate the problem.

Students who feel cared for, accepted, and understood by a school nurse, who approaches them with the warmth of unconditional positive regard, consistency, and empathy, are more likely to respond with openness and trust. Development of a relationship with the school nurse can foster a sense of attachment, an important factor in feeling connected to school as a place where the adolescent wants to be. The use of a person-centered approach through Intentional Interviewing can provide the practicing school nurse with a useful framework to work with students, whose somatic complaints may be a sign of psychoemotional concerns. The school nurse can identify students who need assistance with these concerns and can then refer them to school counseling personnel, their primary care provider, or to outside mental health professionals, as part of interdisciplinary care.

According to Gapinski and Giulian (2009), many current school nurses report that they feel ill-equipped and minimally supported to assess and intervene with students who present with symptoms that may be related to psychoemotional issues. Intentional Interviewing is an approach that can be easy for school nurses to learn and employ. Workshops and other educational opportunities need to be designed to help school nurses increase their competence and confidence in conversing with students who have concerns that are likely of a psycoemotional  origin. Skill-building opportunities should be experiential in order to allow for practice with the approach of Intentional Interviewing and microskills model, so as to increase comfort and facility in bringing the approach back to actual day-to-day school nursing practice.

School nurses also need help in learning how to create culture change at their high schools as to their role in case finding. Formal alliance with the school counseling staff is essential and requires a working relationship rooted in collaboration and reciprocal referral. Administrative appreciation of the school nurse’s unique and legitimate role as a source of emotional support for students and as a valuable case finder is paramount. Schools with high nurse-to-student ratios may not have the time to interact with students in a meaningful way to develop the kind of relationships that lead to case finding. Support for an adequate student nurse ratio by administration is also a necessity.

As reported by Shannon et al. (2010), there is a lack of empirical evidence as to which interventions by school nurses are most effective in working with students who regularly visit with somatic complaints that cannot be attributed to objective physical causes. Additional research is needed to learn more about how to best care for frequent visitors to the school nurse, whose somatic complaints disguise that they are suffering in silence. Research could be designed to test the use of Intentional Interviewing as a tool to maximize the effectiveness of school nurse encounters with frequent visitors. Being truly seen and effectively heard by the school nurse can be a troubled adolescent’s first step toward the development of a trusting, helping relationship leading to effective intervention.

Adria Pavletic is the Director of Health Services.  She lives in Hopkinton with her veterinarian husband, five dogs, one ball python, and two daughters who occasionally land at home.  Adria follows the Patriots in the fall and enjoys watching “Breaking Bad.”

References:

Gapinski, M. A., & Giulian, A. (2009, June 27). Transforming school based mental health services: A public health model. Lecture presented at National Association of School Nurses, Boston, MA.

Shannon, R. A., Bergren, R. A., & Matthews, M. D. (2010). Frequent visitors: Somatization in school age           children and implications for school nurses. Journal of School Nursing, 26, 169–182.