When the Nurse's Office is a Refuge

The vital, overlooked role of school nurses in combatting student anxiety

November 30, 2017
Comic strip of a teen trapped under bricks, and then a school nurse helping him build a ladder with the bricks

As more and more children struggle with anxiety, school nurses are in a unique position to aid overloaded school clinicians and fill in the gaps by extending support to students who need it. Nurses often know exactly who those struggling students are, since anxiety's calling cards include physical ailments like headache and stomachache. Why not enlist their help in a more intentional way?

“There’s something nurturing and comforting about the school nurse,” says Golda Ginsburg, a professor of psychiatry at the University of Connecticut who has studied anxiety in young people for more than 20 years and is now developing simple tools for nurses to use with anxious students. “Though there are many students who love the school clinicians, there is another group that doesn’t want to see the counselor. A school nurse can do something under the radar, and for those students not dealing with severe issues, a school nurse can do some preventative work.” 

“School nurses are often the first point of contact with anxious students. They have a fabulous reach and a role in schools that creates an opportunity to help these kids that’s been untapped.”

In a recent study funded by the U.S. Department of Education’s Institute of Education Sciences, Ginsburg developed and tested a brief nurse-administered intervention to reduce anxiety symptoms and improve academic functioning in 5- to 12-year-old children. She gave nurses the tools to help students identify and confront their anxious feelings in several 15-minute sessions, a strategy that differs from the more typical responses, like offering the student a chance to lay down, or offering to call a parent.

The study found that nurses are capable of doing this work — and also that it resulted in significant reduction of children’s anxiety.

Ginsburg is creating manuals and training videos based on the intervention, which she hopes to make available to nurses in the coming year. “We want this to be something nurses can easily do,” she says. “We don’t expect them to be therapists, but teaching basic skills can be helpful.”

We asked her to describe how the intervention works.

With an anxious child, their thoughts revolve around danger, threat, and fear: “What if I fail?” “What if I have cancer?” 

Understanding the signs of anxiety in students

Anxiety typically manifests in three ways — whether in adults, children, or adolescents.

  1. Watch for physical complaints that occur without a medical explanation — like recurring stomachaches, headaches, nausea, shaking, or other signs of tension.
  2. Watch for unrealistic thoughts and thematic patterns in a child’s thinking. With an anxious child, their thoughts revolve around danger, threat, and fear: “What if I fail?” “What if I have cancer?” The message from an anxious child is often that something bad is going to happen, says Ginsburg, which is different than the message from children who are depressed. Those young people may talk about not being good enough, or feel pessimistic about whether something will work, or feel guilty about something. But anxious children often demonstrate unrealistic thoughts about danger and threats.
  3. Watch for behavior that may indicate anxiety — avoidance, reassurance-seeking, worrying. As Ginsburg points out, the behaviors might manifest differently depending on the anxiety. A child who is socially anxious might not raise her hand in class, talk to other kids, or use the public bathroom. A worrier might ask a lot of questions and need a lot of reassurance, like, What if the bus breaks down? What’s going to happen tomorrow? Did I do OK on the math test? What happens if I failed it?

Most likely, nurses already know which students are seriously struggling with anxiety. It’s not the student who comes by the office once or twice a year complaining of a stomachache, Ginsburg says, but the student a nurse sees regularly. It’s that persistent anxiety that is most concerning — those students for whom getting an A on one test immediately triggers worries about the next one.

The key is helping a child understand that in some cases, the body’s alarm clock goes off at the wrong time, resulting in a headache or stomachache. We aren’t in danger, but it still feels like something bad is about to happen.

Approaching a potentially anxious student

As part of the intervention, nurses invite struggling students to take part in a program that helps ease and confront anxiety. A nurse might say, “I have a program that helps children who have stomachaches.” Use flexible, age-appropriate language; depending on the child, you might use the term “anxiety,” or you might use “stomachache.”

Then, nurses can explain the role that anxiety plays in our lives. Ginsburg uses the analogy of anxiety being our body’s alarm clock, telling us that something dangerous is happening, like seeing a bear come into the backyard and deciding to run. The key is helping a child understand that in some cases, the body’s alarm clock goes off at the wrong time, resulting in a headache or stomachache. We aren’t in danger, but it still feels like something bad is about to happen.

Then, the nurse can say, “I’m going to teach you how to change that feeling so you can sit through class or be away from mom or sit in the cafeteria and do what you feel too upset to do right now.” 

How Nurses Can Respond to Anxiety Effectively, Strategically
  • For anxious children with physical complaints, teach them to relax their bodies. Some videos on YouTube can be useful, and nurses can practice relaxation skills alongside the children.
  • Focus on addressing a child’s thinking. If a child is having unrealistic thoughts about failing a test, the nurse can gently challenge those thoughts into more helpful and realistic responses. Ask: What happened the last time you failed a test? Did the teacher yell? Was the teacher helpful?
  • Work to bring a child’s thinking back from the catastrophic — everything is awful! — to a place where they believe they can cope.
  • Confront the child’s fears. Talk about them, while offering support and coping skills. Work toward getting the child to a place where rather than go to the nurse, the child can say, “I feel anxious, but I can get through this class.”

Illustration: Wilhelmina Peragine

***

We’re in a moment where anxiety is running rampant, spreading like an epidemic among adolescents. What can we do? In a series of pieces, we look at how to help teenagers face their fears, build resilience, and grapple with the pressure to achieve — on the road to college and beyond. Read more at What Do Anxious Teens Need?

See More In
K-12 Mind and Brain Social-Emotional Wellbeing

Usable Knowledge is a trusted source of insight into what works in education — translating new research into easy-to-use stories and strategies for teachers, parents, K-12 leaders, higher ed professionals, and policymakers. Usable Knowledge is produced at the Harvard Graduate School of Education by Bari Walsh (senior editor) and Leah Shafer (staff writer). Contact us at uknow@gse.harvard.edu.