SCHOOL HEALTH 04.04.13

Traditionally, school nurses have worked within a framework of the Medical Model, (ie health is the absence of disease, illness or injury.) Today’s school nurse must think out of the box when it comes to the “frequent flier. “

What approach should the school nurse take with the student who frequents the health office, often with no overt issue at hand?

In a case with a “frequent flyer” who visits the school nurse often, it is important to follow the Medical Model as well as thinking outside of the box. According to Somerville Public Schools, school nurses “offer facilitate positive student responses to normal development, promote health and safety, intervene with actual and potential health problems, provide case management services, and actively collaborate with others to build student and family capacity for adaption, self-management, self-advocacy, and learning” (Somerville Public Schools, 2013). With the child who is a frequent flyer with no overt medical issue at hand, the nurse must further assess the situation to attempt to determine the reason for the child’s visits. As mentioned in the quote, the nurse may need to “provide case management services” if the child was having difficulties with situations at home and bringing them to school with him. Also, the definition explains that the school nurse aides in adaptation. This may be an issue the child is facing. Adapting to new school system or a different environment than the home setting may be causing the child a great amount of anxiety and he may not feel comfortable. It is important to address this and see what can be done to make the child more comfortable and happy in the classrooms. The school nurse also promotes self-management (helping the child identify problems and handle them appropriately) and self-advocacy (voicing to the nurse what is occurring and causing them trouble). The nurse should assess all of these possibilities with the “frequent flyer” by having a conversation with them in a non-stressful environment. The nurse may be able to discover the child’s reasoning for visiting the nurse, and the nurse may be able to make this child more comfortable and happy at school.

Today, the school nurse cannot only use the Medical Model, which views health as the absence of disease, illness, or injury. Now, school nurses must also look at the child’s emotional status and mental health. Anxiety and comfort affect children greatly when they are in school, caused by being away from home, learning a different environment, fearing getting bad grades, fearing being bullied, and many more. It is important for the school nurse to talk with the child and discuss these occurrences to determine if the child is facing any of these problems when they frequently visit the nurse. They may view the nurse’s office as a comfort zone, and they may enjoy being there more than their classrooms.

(Somerville Public Schools. 2013. http://www.somerville.k12.ma.us/education/dept/dept.php?sectionid=1234)

Many times a school nurse will refer to certain children as "frequent fliers" who come into the nurses office more than once a day with no real complaint. The nurse has to be aware that there might be an underlying issue with this child, and that's why they present themselves so much to the nurses office either trying to go home or just out of class. There might be an issue at home with the child or in the classroom and the nurse needs to explore what is really going on with the student. This week at my school I saw the frequent fliers, who turned out to have some serious issues in their homes where they just couldn't sit in the classroom and concentrate. One girl presented to the office saying that she had wet her pants, even though the class just went to bathroom break 20 minutes before. The girl started lying to the nurse saying that she had no dry underpants or pants in her locker, but she actually did, and she was trying to go home. The nurse knew that something wasn't right with this student so she asked the student what was really going on and why she was lying about the pants. The girl started to cry and said she was worried that someone was going to take her baby brother away because this family had DSS involvement. This situation taught me that you can't just assume that "frequent fliers" are just trying to get out of class because they are bored or don't want to be there, you have to further investigate. The nurse needs to also collaborate with the students teacher to see if the student has been acting different in class or if they noticed a change in the students performance if the nurse suspects that there is an issue but the child wont talk about it.

Labeling a student as a “frequent flyer” can be a dangerous scenario. Today nurses have do not only deal with traditional disease, injury or illness, but also psychological issues the child may be dealing with. Labeling a child as a frequent flyer, may cause the nurse to overlook an underlying issue, which needs to be addressed. In the article, “Victimization, Aggression, and Visits to the School Nurse for Somatic Complaints, Illnesses, and Physical Injuries” the authors describe a reason why children may be frequenting the nurse’s office, “Stressful events have been linked to somatic symptoms, both in general and on the day of the stressor” (Fongay, Nelson, Twemlow, Vernberg, 2011). As a society we are all aware that bullying is a major issue that young children and adolescents cannot escape. Ongoing bullying has had devastating outcomes and school nurses should try and understand if there is a form of bullying or abuse going on before labeling a student a “frequent flyer.” The research conducted in the article stated above concluded “The results of this study suggest that involvement in aggressor-victim interactions can have negative effects on children's health, as measured by visits to the school nurse's office”( Fongay, Nelson, Twemlow, Vernberg, 2011). Unfortunately there will always be children and adolescents that frequent the nurse’s office, who may have no underlying issue, yet I think the nurse needs to do a thorough investigation before labeling a child as a “frequent flyer.” The school nurse should talk to the child about the frequent visits, and check to see if there are any visible marks indicating abuse, on body parts that are exposed. The nurse should also speak with the school psychologist and guidance counselor to see if any other complaints have been made by the teacher. If a child is having psychological issues, these issues need to be addressed, because frequenting the nurse’s office may be a child’s cry for help.

Fongay, P., Nelson, D. T., Twemlow, W. S. & Vernberg, M. E. (2011).Victimization, Aggression, and Visits to the School Nurse for Somatic Complaints, Illnesses, and Physical Injuries Official Journal of American Academy of pediatrics , 127(5),pp.842-848. http://pediatrics.aappublications.org/content/127/5/842.full?%3f

LM your story shows the importance of investigating why a student would frequent the nurses office. Assessment skills not only need to be geared towards physical needs, but psychological needs instead. In these cases I feel it is important for the nurse to reach out to other disciplines in the school so everyone is on the same page in trying to help the child get through the hard times at home.

A school nurse seems to be one of the most therapeutic tool to most students in a given school. As a nurse, you are taught to nurture and not be judgmental of your patients/clients who might present as frequent fliers in a given school. The question remains, how many visits does a student have to make to the nurses office in order to be categorized as frequent flier? Most students/kids dont realize how much missing class time might be affecting their academics and therefore l feel like their parents should be notified for such behaviors. Parents should be encouraged to talk to their children about the advantages of uninterrupted daily academic work. However, we should not prejudge this behaviors since some children rely on the nurse for moral and social support, incase things are not going well at home.

However, l feel like all the disciplines should be involved when this behaviors apply to a given child for no significant reason. The social worker, school councilor, the principle or personal care Doctor should be contacted to help alleviate some of the problems a student may have. In one of the journals of school of nursing, it is stated that, frequent fliers are associated with stress, depression, anxiety, lack of teachers support, domestic violence and bullying. i feel like most frequent flyers should be assessed for any of this effects which may be affecting their activities of daily living, and therefore avoid being judgmental. The school environment should be made as conducive as possible to improve the students academic performance and healthy status.

As you clearly explain the need to evaluate the school children appropriately, a school nurse should have excellent assessment skills, non-judgmental and a good communicator. To add to your points, at times l feel confused, should bullies be tolerated in schools, l feel like they bring a lot of trouble to the other kids and in turn, they run to the nurse for support, bullies should always be properly dealt with to avoid turning some other kids to being frequent flyers. However, parents should be involved as much as possible, since they know their children much better, especially if the behavior becomes remarkably increased. Also, further investigation with this behaviors should be conducted to decrease frequent flyer reactions within a school setting.

In the health care field, we see “frequent flyers” all the time, whether we work in a clinic, a doctors office or a hospital. Whether or not these people are really sick and in need of medical attention is up to the medical professional- doctor, nurse, aide, what have you. We especially see this in the school nurse setting. I remember being in high school myself- there were always a select few people who frequented the nurse’s office. I can imagine that as a school nurse it may be difficult to figure out why these kids are in the office so much- it could be as simple as not wanting to be in class but it could be something more serious like issues at home or a mental health issue that needs to be addressed.
When I was with the XXX school nurse on Wednesday, we had a girl come in who just wanted to lie down for a few minutes because she was feeling very anxious. After she left the room, the nurse started telling me a little bit about her background story. She grew up in a broken home, her mom an alcoholic and there was no dad in the picture. Earlier in the semester, the nurse noted that student had been visiting the nurse’s office quite often so she invested some time of her day to sit down and talk with her. The nurse found that the girl was having some issues and was going to see a psychologist. As the student got up to leave, she very nonchalantly mentioned on her way out that she was probably going to be diagnosed with schizophrenia. The nurse knew enough to stop her and bring her into her office to chat with her some more. Turns out the girl had been having visual and auditory hallucinations and had gotten into her mothers pills the week before and attempted to kill herself. She said she had told her mother about the way she was feeling but the mother didn’t seem to care. Further action was obviously taken by the nurse and the student got the medical attention she needed. She is now recovering, but the point of the story is if the nurse had just dismissed this girls comment as silly or just brushed her off like her mother did, the student could have ended up dead. Some students may be labeled as “frequent flyers,” but sometimes there is more to the story than what meets the eye and it is the nurses responsibility to assess the patient and investigate.

Thanks for telling your story about the child you saw in your school. I think a lot of people would especially brush off the stories that children say especially at the elementary school age. They are in the age of pretend and make believe and a lot of them are good at "telling stories." I applaud the nurse for getting on the child's level and confronting her about what was really going on. If she hadn't asked her why she was lying, the nurse never would have known the issues that were going on at home.

Reply to JC,
As you mentioned, labeling a child as a frequent flyer can be very dangerous. It is unknown if there is an underlying cause to the student visiting the office so frequently. You have a great quote about how stressful events can cause children to feel symptoms, and most likely they may not be able to identify the cause of these symptoms as stress. You make a great point to involve the school counselor or psychologist too with these children. It is true that visiting the nurse’s office may be a cry for help and they feel comforted by being in that environment rather than their classrooms. Investigation and assessment is definitely important with these students.

When dealing with “frequent fliers,” the school nurse should approach the situation from both the Medical Model as well as thinking outside the box. Many times children seek out the school nurse as someone who can help them, even if they may not be physically sick. During my first day with the school nurse we saw over 60 kids, but a few stuck out because of their return visits. The school nurse I was with told me their background stories, and as I suspected these children were often neglected by their parents. It is important for the nurse to be aware of these children’s personal and home lives because it strongly impacts their development and schooling and it can help one understand why these children need to visit the nurse’s office so frequently. The child’s emotional and mental well being is just as important as the physical well being and needs to be assessed and cared for just like any physical problem would.

I found this to be a good summery of who typically makes up the frequent fliers and what is the best way to deal with them:

“Nurses associated FVSNs (Frequent visitors of the school nurse) with certain characteristics. The thematic categories were difficulties with 1) academics, 2) peer relations, 3) teachers, 4) home issues, 5) stress/anxiety, and 6) FVSN individual personality constitution”
The nurses recommended treatment for FVSNs according to thematic patterns:
1. Respite and recovery;
2. Rituals and routines; eg, take temperature, lie down;
3. Relaxation, refocus, and regrouping;
4. Reframe for stressful or unpleasant situations;
5. Reassurance;
6. Rule out serious medical issues;
7. Return to class;
8. Referral to a counselor; and
9. Rally team resources to remediate the problem.
The interviews generated an FVSN composite as the student who has a high need for security, nurturance, and/or a need to attach to an adult at school.” (Sweeney, 2000)

Sweeney, J., & Sweeney, D. (2000). Health service applications. Frequent visitors to the school nurse at two middle schools. Journal Of School Health, 70(9), 387-389.

I agree that the nurse needs to do a thorough investigation before labeling a child as a “frequent flyer.” Talking to the child about the frequent visits, speaking with the school psychologist, the child's teacher and guidance counselor to see if any other problems have been noted are necessary actions by the school nurse in many cases because this child could be reaching out for help and it is important that the child be heard.

This semester is the first time that I had heard that the absence of disease, illness or injury does not translate into good health. I think the thought of such a statement to be absurd. This public health course has been a course of reality and make believe. I’ve come to see that a certain group wants to be able to dictate what an individual may do through the guise that is public health. The professors have made the link that everything we do is a public health concern such as taking in a Red Sox game with your family, to tying your shoes and even global warming. The global warming people could not with stand the argument of things like temperatures declining in some areas or a particularly harsh winter. What they did was to change the name to climate change, now affording them the luxury of now being able to claim any weather to be a result of global warming. I fear that there may be a similar principle behind the statement that being of good health doesn’t mean being healthy. By following this mantra all peoples are perpetually in a state of illness and needing policies as well as guidance from those folks pushing this idea.
I understand how the absence of illness and the frequent flier connection is being made here, and is interesting one given my previous statements. I have two takes on this, that there may an underlying issue or the “illness” if you will, and/or that the student is in an all-around healthy state.
A child who comes to the nurse’s office complaining of various alignment may appear healthy outwardly but may be in crisis or lacking in mental health. This week, I had spent a day at a local high school as part of my clinical experience. We had a student come in with complaints of an upset stomach and headache. The school nurse indicated to me that this was one of the frequent flyers. She told me of troubles at the student’s home and that the student is quite involved with social workers and guidance counselors at the school. At some point the student confirmed that he comes to the nurse’s station for attention and as a diversion. The student is clearly mentally unwell and intervention have been put into place that will help him. The school nurses were the ones that brought attention to the matter. They didn’t go into how they determined something was wrong other than the frequent visits but I’m sure it was through interpretation of responses, demeanor, presentation, and attitudes. These are all areas that manifest themselves outwardly while being an internal matter. So the idea of being healthy, while not truly being is being displayed here.
On the other hand some of the frequent flyers may be coming in to see the school nurse for mental health issues but are in fact healthy. Let’s try to view the student’s actions above as healthy. The student was not running away, drinking, cutting himself etc.. He was seeking affirmation and attention at some level from which he was lacking. This is a normal and healthy response to a critical area especially at this age. We have serial killers who kill without emotion and we call them mentally ill, so the student demonstrates the opposite, as having emotions, and we still label him as mentally ill/unwell? It’s also normal to feel negative emotions and is a good thing like pain being a good thing for what its natural purposes are.
I think that in a way students negative feelings are being portrayed more as destructive and inflicting mental anguish. We are doing away with test failures, trophies in sports, and even winning! The school nurse should assess the totality of the situation and must find a way to discern a true mental wellbeing issue vs. that of life issues and part of growing up. The school nurse should bring to the team perceived harm being done to a student for further evaluation and intervention as needed.

It seems we have taken similar view points and angles towards answering this discussion. Its important not to just assume a student coming in to see the school nurse has some sort of under lying issue when a frequent flyer. Sometimes a student may be coming in because they do not want to take a math test or to get sent home sick, so they can hang out with friends. These are parental issues and should be handled at the teacher level. With that said, I agree with making allowances for those frequent flyers who may be coming in with true underlying issues. I think that much of the assessment being conducted by the school nurse is not lung sounds, etc.. or even a Q & A session but is done through more of a nursing intuition. Research by Fleming (2011) found that poor students visited the nurse more frequently with greater complaints of illness, and among all other areas studied. The recommendation being to next follow up with a study to determine % of actual illness. Interesting!

Fleming, R. (2011). Use of school nurse services among poor ethnic minority students in the
urban pacific northwest. Public Health Nursing, 28 (4), 308-316.

Working with the school nurse, I have seen first-hand the difficulties presented with dealing with frequent flyers. It is imperative however, that we investigate the issue before labeling a student as such by using the medical model. If we initially write off a student as being a frequent flyer without assessing whether they have an issue or not, we may miss the true reason why the student may be frequenting the nurses' office.

Often, children who are frequently visiting the nurses' office are suffering from being bullied or in the bullies' case (being abused). The psychological stress caused by bullying could compromise kids’ immune systems and make them vulnerable to sickness. "Bullied kids may become anxious, not want to go to school, complain of headaches, or drop out of favorite school activities" (Readers Digest, 2011).

Having explored this possibility of children frequenting the nurses office, it is vital that the nurse doesn't write off a student as a frequent flyer without exploring the nature of their visits deeper. School nurse's have a duty to report frequent visitation to the childs' parents/guardians and possibly the principal to find out the cause of the problem.

Editors, R. D. (2011). Study links frequent school nurse visits to bullying. Reader's Digest, Retrieved from http://www.rd.com/advice/parenting/study-links-frequent-school-nurse-visits-to-bullying/

I couldn't agree more about the importance of assessing before labeling a student as a frequent flyer. Children who are dealing with stressful situations can often present with actual symptoms like GI discomfort and headaches and must be treated as such. This however is merely putting a bandaid on the issue, rather than fixing the problem. Schools must have strict policies against bullying.

This is same happened to me.....