School Nursing

The Relentless School Nurse: When the Health Office Pass Includes Emotions!

The collaboration between school counselors and school nurses creates safe spaces for students at school.  Building a coalition between school counselors and school nurses creates a safety net for our most complex and challenging students while benefiting the whole school community. Promoting connections through intentional relationship building, and ensuring a school environment that is physically, emotionally and psychologically safe changes the culture and climate.

Read about an amazing collaboration between school nurse, Rebecca Kilfoy, MSN, RN, ACNP, NCSN and school counselor Sarah Weber, M.A., M.Ed. that is an exemplar of what a true partnership can manifest. This week’s guest blogger, Rebecca, shares her journey to address the confounding problem of students who somaticize underlying mental health concerns. We all have the experience of students who repeatedly present to the health office with vague physical complaints masking anxiety, depression or stress. 

Rebecca teamed up with her school counselor to tackle the patterns they were seeing head-on. Students were losing precious class time and even undergoing unnecessary medical testing (in some cases).  They went upstream to address the challenges students were exhibiting by introducing an Emotion Management Program beginning in kindergarten! Read their success story! Congratulations to Rebecca and Sarah, two champions of children’s mental wellness!

Rebecca Kilfoy, MSN, RN, ACNP, NCSN


Thank you Robin for inviting me to share our story about collaborating with my school counselor to equip our children with stress management techniques starting in kindergarten. I am Rebecca Kilfoy, Nationally Certified School Nurse and my colleague Sarah Weber is our school counselor.

I am excited to share with you and your followers the Emotion Management Program we developed together and have been implementing in our school over the past year, continuing again this year. It is our way of supporting a healthy and a socially and emotionally strong school environment.

Sarah and I had been talking at the beginning of the 2018-2019 school year during one of our daily walk-about. The walk about was recommended to us by our Principal when we both started at our school. He insisted that we use our planning time in the mornings to grab a cup of something and head out to talk with the staff about the children, their lives or really anything that comes up. These walks removed us from our tiny islands in the office wing where we are often times isolated during the school day and enabled us to connect and develop relationships with the teachers. This valuable time in our day is now devoted to making these connections and developing a trusting relationships with the staff we are so dependent upon helping us achieve our goals to maintain a safe and healthy school environment. It has easily become my favorite part of the day and has been a valuable tool in building relationship with our teachers. As we walked, we were talking about my Health Office and what our goals for the year would be.

In my 6 years at the school and 8 years as a school nurse, I have identified that the majority of my visits are for illness or a discomfort that really has no organic reason. In many cases a trip to the bathroom, a drink of water and a mint send these kids back to class with no further visit for the day. But they are the kids that are repeatedly coming to my office or calling on Mrs. Weber for help. We knew we could be doing more to help these kids and perhaps reduce the amount of time they were spending outside the classroom traveling to our offices.

So I started to look into the research and identified a few articles written about Somatization. Somatization is a medical phenomenon where a patient presents with a debilitating physical symptom and after medical examination and testing no organic cause for the symptom is found. This is a common problem we see in our primary care offices and our school nursing offices. The research for addressing this condition in school is limited. I reached out to my nursing colleagues across the country and indeed we all see it but due to busy offices or lack of resources it is not really addressed.  The children keep coming and we try our best to help relieve their physical symptoms with what we have on hand. Tylenol for headaches, antacids and crackers for stomach aches, cough drops for “sore throats” and rest when all else fails. I seldom send a child home because they are not sick. They leave our offices pacified but really what did we do to help the cause for the visit?

Sarah and I both studied Social and Emotional Learning in a graduate Master of Education program out of Neumann University. In class discussions with other educators, we often times discussed the frequent visitor, those kiddos that seek out the nurse multiple times a week, and the effects on the teachers’ classrooms. The theme I was hearing from classroom educators was how do we get them to stay in class, engage in learning and minimize their disruptions to go to the nurse.  As I had stated, studies are limited but those that have been done on somatic symptoms in school aged children indicate that stress is the primary reason for the symptoms. We are not doing enough to address the emotional needs of the child. 

The studies show consistently that about 10% of children somaticize and end up presenting to primary care physicians with a condition called RAP (frequent unexplained stomach ache). The term RAP describes children with at least three episodes of pain over a period of 3 or more months severe enough to interfere with the activities. I have a child in school now undergoing medical examination for this disorder. She presented to my office 24 times last year. I discussed the frequent visits with her parents and referred her parents to their physician. They were unable to identify a physical cause for her stomach aches. 

These children can end up going through needless and risky medical procedures, because we cannot ignore their pain but often, no medical reason is found for their pain. Parents are frustrated as well as teachers because they miss a lot of school. With this many children experiencing this phenomenon one has to ask, “What is really going on with this child and how can we help?” As a school nurse I feel it is my responsibility along with the school counselor, classroom teacher and family to identify these children and get them the help they need.

The National Association of School Nurses agree that research is needed to addresses mental health issues and screening tools, the importance of a school nurses in every building and the effects on academic outcomes related to frequent office visits for somatic symptoms. This is research I hope to do one day as part of a Doctoral program I will be starting soon.

We know that children that somaticize are at increased risk for anxiety and depression as well as other psychopathologic illness. They have increased school absences, emotional and behavioral difficulties and ultimately academic and relationship problems. We can probably count on two hands kiddos we work with every day that resemble this profile.

In order to talk about treatment we need to identify risk factors so we are sure we target the appropriate community. Risk Factors for somatization include

  • Childhood adversity which refers to extremely difficult circumstances experienced by children such as poverty, abuse or neglect, and exposure to violence. Adverse Childhood Experiences or ACEs is a buzz term getting a lot of attention by pediatricians and educators.
  • School Stress. These are your children that are bullied and often times just teased enough to elicit a physical response. Bullied children were over four times more likely to develop depression, three times more likely to have anxiety or feel tense, almost five times more likely to wet the bed, and more than twice as likely to report pain, tiredness, or poor appetite. These are the symptoms I see in my office. I think when we talk about school stress we also have to address academic pressures as well as digital media’s effects. These are topics for a whole other discussion.
  • Social isolation or alienation are also other risk factors.

The last question to be answered is what causes somatization. The research found significant correlation between somatization and stress. Stress was the number one cause of somatization in school aged children. As the School nurse I am uniquely qualified to holistically address the mental and emotional needs of students from physical, psychological, and social perspectives.  It is my role to recognize somatization behavior as a potential early identifier of mental health needs and stress in a school-aged child. As the school nurse, I see these children every day, year after year and because of my consistent presence in their lives, I have become a trusted adult to seek help from. Because of my relationship with my school counselor, a team if you will, we are in a position to make real change in their lives and support their mental health.  She addresses much of the emotional component in her guidance lessons, but these are only provided to K-3 in our building. What do we do to reinforce in the 4-6 population of kids? Those that are really starting to see the effects of external stress in the form of social media and academic pressures. This is why it is so important for all schools to have a certified school nurse and school counselor on site all day, every day.

We have all been there, a stressful time in our lives when our bodies respond with an elevated heart rate, dry mouth, and abdominal upset.  We know what stress feels like in our adult bodies. We can identify our feelings because we have years of experience with these feelings. For a child, stress is a new phenomenon. The feelings of fright, flight or freeze can often times be confused with illness. The children are confused about what to do with these feelings. Our plan helps to give them ways to move forward rather than just coming to the nurse for me to solve it for them. We know our children with adversity and hard tough lives at home must be feeling this sensation almost daily. For them the long term effects of stress are causing other symptoms and illness as well. But we also need to consider our children from that “perfect” home. These children are often times being raised in sheltered and happy environments, where every need is met and every desire fulfilled. But these children too experience ACEs and stress. And as they grow and develop into middle school and high school students, social and academic pressures increase and stress magnifies. Again a much bigger topic for another discussion

Let’s move on to what we can and are doing in our school to address stress in our K-6 community.

As the school nurse and the school counselor it is our primary goal and objective to assure we are providing a safe and healthy environment for our students and staff. School Wellness is more than just band aids and vomit bags. Through development of therapeutic relationships and interdisciplinary interventions, as a team we are able to address the social and emotional health of our children by mitigating the effects of school stress, childhood adversity, neighborhood violence and other psychological co-morbidities. These are things we see every day in our schools and the children need our help to manage and develop skills to cope.  We promote a culture of kindness and caring in our building that takes priority. Sarah in her role as a school counselor under pupil services collaborates with outside therapists to formulate and support the cognitive therapies prescribed and working together we developed an Emotion Management Program to address the stress our children are feeling.

So I ran the numbers. In 2018, I saw 3053 students. While my send home rate is below national average of 10%, I do represent the 10% somatization numbers. I usually send home for vomiting, fever and diarrhea only. My stomach aches and headaches stay in school with coaching. My average office visit lasts about 15-20 minutes for these complaints. This is time lost in the classroom, for many students multiple times a week and usually around the same time of day.  This data tells me, they are avoiding school most likely due to a strong emotion. Treatment was just a bathroom break, temperature, drink of water and maybe a lie down. Mints also help. I was going through a ton of lozenges and mints. But was I really helping because they were just coming back again in a day or two with the same complaint or something new.

Our Emotion Management program has five parts. This all started with a restructured nurse’s pass to include not only illness and injury for reason to visit but also include emotion as well. The nurse pass also includes these tools as a “three before me” approach to self-care. On the reverse is an area for me to communicate with the teacher and the child about what we identified and did to care for ourselves. These passes can be kept in their desk as a resource for future illness.

We first meet with each grade as a whole. In this time we talk to the children about what a strong emotion looks like and feels like. We may do a game to get them stressed and then talk about how their bodies are responding. We talk about all the different feelings we can have and what would make us feel that way. Feeling nervous because you did not prepare for the math test or forgot your homework and you know your teacher will be upset. Sad because you had a disagreement with a friend at recess and did not have time to resolve it before the whistle blew. Anxious because your mom is in the hospital and grandma is watching you but does not know how to take care of your needs.

The next step is a 30 minute classroom lesson where we demonstrate up to six different calm down techniques and allow practice time. These include guided meditation, imagery, five senses grounding, art, journaling and mindful breathing. These lessons can be adjusted to grade level and we ask that the teachers stay behind to watch. Many of the teachers have reported using these tools for themselves. The children leave the lesson with a desk card that has a pictogram of three of their favorites. We provide each classroom with a flip chart tool that describes each tool for use in the classroom. The card is kept at their desk to remind them of the tools and assist teachers in keeping them in class rather than sending to the Health Office. Feedback from teachers has been promising. The kids are using the cards and staying in class.

I have developed an emotion scale and it is part of assessment now with every child, a sixth vital sign if you will. When a child comes in now with a somatic complaint, I ask them to identify an emotion. We discuss class and what they are learning. I have been able to identify anxiety about math, reading and writing. When I attend IST meetings now, I come with data to assist the team in identify struggling students or supporting those already identified. I have had discussions with families which have then helped them to help their child at home.

The third step includes 5 minute pop ins where Sarah or I will push in for just 5 minutes to review a tool, talk about an emotion the class may be feeling, discuss friendship issues or just play a game and discuss what SEL skills were used to be successful. These pop-ins serve as a way for us to stay connected in in front of the students letting them know we are here and care about them. We become that constant for them. With teachers and classmates changing every year, we are the consistent person in the school there for them.

The fourth and fifth steps involve the parents and the community. We hold breakfast meetings where we invite in special guests to talk about stress management and healthy lifestyles. We also have a monthly newsletter that we send home that includes the stress management techniques taught in the lessons along with home challenges to encourage use at home.

As with any new adventure, there are hurdles to overcome. We had full administrative support to be out of our offices for the lessons. This was essential for the programs success. Teachers were resistant at first to give up 30 minutes of academic time for this. I asked them to just give it a chance. It is just one 30 minute session. These 30 minutes lost have gained them the ability to ask the child to self-care, wait for a transition time to leave if needed. Rather than sending the child to me, the child stays in the classroom. Teachers were concerned about manipulation of the tools to avoid work. I explained, and correct me if I am wrong, is it not better to allow the child to pull out a sheet of paper to color or doodle while you give instruction and be there to hear the instruction or have them interrupt you every two minutes to come see me or eventually lose them to the Health Office for 20 minutes? Better to let them rest their head or deep breath in the corner while still hearing your instruction?

My practice in the Health Office has changed for the better. I am now practicing with a greater sense of pride of what I am providing to the students and their families. Sarah and I along with our Principal and staff are rolling out an entire Social and Emotional Learning program to the students this year. Our Superintendent along with the School Board has recognized the importance of a fully integrated SEL approach in educating our children. I am proud that the Health Office can be a vital part of this work. The students still come to the office but now they come with authenticity and honesty about what is bothering them. I am then better able to assist them in a more meaningful way. My mint supply hasn’t run out.

Here is the SEL Health Office Pass, a link to download the document is included at the end of the blog post:


Shannon, Bergren & Matthews. (2010). Frequent Visitors: Somatization in School-Age Children and  Implications for School Nurses. Journal of School Nursing, 26(3),169-182.

Lavigne, Saps & Bryant. (2013). Models of Anxiety, Depression, Somatization, and Coping as Predictors of Abdominal Pain in a Community Sample of School-Age Children. Journal of Pediatric  Psychology,  39(1) 9–22.

Bio: Rebecca Kilfoy, MSN, RN, ACNP, NCSN: School Nurse West Vincent Elementary – Owen J. Roberts School District.  Rebecca is a school nurse serving Kindergarten through 6th grade in an elementary school in Chester County, Pennsylvania. She specializes in a holistic approach to childhood wellness. She incorporates evidence-based medical approaches and social and emotional techniques to foster wellness in her school community. With nearly 25 years of nursing experience, Rebecca uses innovative approaches to protect and promote student health, facilitate optimal development, and advance academic success.

Rebecca’s current passion is the integration of social and emotional concepts into her nursing suite to promote Whole Child wellness.  This holistic approach assures students’ academic success and lifelong skill development to cope with the ever changing social environments.

Rebecca earned her B.S.N at the University of Scranton, her M.S.N. – Acute Care Nurse Practitioner at Drexel University, N-C.S.N. at Eastern University and is currently completing her M.Ed. in Social and Emotional Learning at Neumann University. She is looking forward to continuing her education in Social and Emotional Learning Leadership in a Doctoral program using her research skills to study the success of SEL in the school nursing arena.

      Sarah Weber, M.A., M.Ed


Bio: Sarah Weber, M.A., M.Ed. Social Emotional Learning- School Counselor West Vincent Elementary – Owen J. Roberts School District:  Sarah Weber is a school counselor who works in an elementary school serving Kindergarten through 6th graders.  She specializes in individual counseling, group counseling, and a teaching social-emotional lessons in a classroom setting.  Sarah has a focus on integrating social-emotional learning to all areas of a school including building a classroom community in which students feel supported and are able to thrive.  She is a published author conducting research on whether counseling programs are meeting the needs of students.

Sarah is a graduate of the Pennsylvania State University earning a double major in Psychology and Communication Arts and Sciences.  She went on to earn a master’s degree in School Counseling at Montclair State University and a master’s degree in Social Emotional Learning from Neumann University.  She has worked over 10 years in market research and owns a small market research company.  She uses her research background to help strengthen her social-emotional programs with data driven research.


Here is a link to download the SEL passes shared in the blog post:

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