Evidence Based Practice or Policy Reports

The Journal of School Nursing

1-11
Health Services in Boarding School: An Oasis ª The Author(s) 2016
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DOI: 10.1177/1059840516649234
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Adria C. Pavletic, MA, MN, RN, NCSN1, Thomas Dukes, MSW, MS, EdD2,
Jamelle Gardine Greene, PhD3, Jennifer Taylor, MA, CAGS1,
and Louise B. Gilpin, MA, LMHC1

Abstract
Adolescents who attend high school as preparatory boarding students are growing up and learning to care for themselves in a
very different set of circumstances than those who live at home with their families. Although this choice may present myriad
opportunities for personal growth and academic advantages, nurturance and support from caring adults is necessary to foster
health and well-being. Our model of a collaborative relationship between nursing and counseling in providing health services to
the adolescents in our care at St. Mark’s School is designed to effectively meet this challenge. While it is true that a very small
percentage of adolescents attend preparatory boarding schools in the United States, this article is an attempt to present our
working model for consideration by other school nurses and counselors in our field of practice, especially since there is a lack
of professionally relevant current literature for reference.

Keywords
adolescents, boarding schools, collaboration, counseling, health services, school nursing

Introduction The challenges traditionally associated with adolescence

Growing up at boarding school presents a unique constella-
tion of opportunities and challenges for adolescents whose
families choose this option versus the typical choice of
attending high school while living at home. Knowing that
health services is a place to find welcoming, warm adults
who will help when something is wrong, whether or not an
adolescent is able to clearly articulate the problem, is a
comfort to the teenager living away from home and to the
parents who love them. The health services model at St.
Mark’s School is designed to deliver comprehensive,
youth-friendly care to our adolescent boarding school pop-
ulation. Nurses and counselors work in tandem within close
physical proximity to provide an essential oasis for adoles-
cents who attend boarding school.
Adolescence: A Developmental
Perspective
Adolescence is a period of development that can strike fear,
discomfort, and a sense of utter bewilderment in the hearts of
parents, teachers, counselors, and medical professionals
alike. It is a developmental phase as rich, complex, and
challenging as any. And yet, for those of us who choose a
professional path dedicated to nurturing and supporting their
healthy development, adolescents are a never-ending source
of fascination, engagement, and reward.
are well documented. In broad terms, we think of key devel-
opmental tasks as including separation (from family of ori-
gin), identity consolidation, and intimacy. Havighurst
(1951) provided a more specific set of developmental tasks
which included (1) accepting one’s physical characteristics
and sexual role, (2) establishment of peer relationships with
members of both sexes, (3) achieving emotional indepen-
dence from parents, (4) assuring economic independence,
(5) choosing an occupation and preparing for the world of
work, (6) developing the skills necessary for civic engage-
ment, (7) becoming responsible for acceptable social beha-
vior, (8) preparing for marriage and family life, and (9)
building a conscious value system. For Havighurst, ‘‘adoles-
cence is defined as a ‘status passage’ that leads from the
socially dependent life phase of childhood to the indepen-
dent life phase of adulthood’’ (Hurrelmann & Quenzel,
1
St. Mark’s School, Southborough, MA, USA
2
Department of Counseling, Educational Leadership, and School Psychol-
ogy, School Counseling Graduate Program, Rhode Island College, Provi-
dence, RI, USA
3
Private Practice, Framingham, MA, USA
Corresponding Author:
Adria C. Pavletic, MA, MN, RN, NCSN, St. Mark’s School, 25 Marlborough
Rd. Southborough, MA 01772, USA.
Email: adriapavletic@stmarksschool.org

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2 The Journal of School Nursing
2015, p. 264). Today, this theoretical understanding of ado-
lescence remains relevant but requires some important
revisions.
To appropriate the concept of developmental tasks for a valid
analysis of the characteristics of the adolescent and adult life
phases today, a re-definition is necessary which accommodates
all of the important functional aspects identified by Havighurst
but integrates these into a historically and culturally appropriate
frame of reference. (Hurrelmann & Quenzel, 2015, p. 263)
These authors go on to describe the two most salient
factors characterizing adolescence today as status insecurity
and status inconsistency, characteristics resulting from a
temporal extension of the adolescent phase due to earlier
onset of puberty combined with ‘‘arrested adolescence’’
which extends this life phase.
Similarly, Copeland (1974) made note historically of
‘‘adolescent idiosyncrasies’’ that include preoccupations
with self and the need for self-expression, fantasy, sexuality,
and conformism, among others. According to Copeland, the
affective states of adolescents tend toward heightened sen-
sitivity, mood swings, acting out, inhibition, and social with-
drawal. Current thinking and research continue to stress the
pragmatic importance for youth of developing the ability to
understand one’s emotions and use them effectively (Laser
& Nicotera, 2011). It remains widely recognized that the
capacity for such self-regulation is predictive of success in
multiple domains including school and social relationships
(Farley & Kim-Spoon, 2014).
Finally, we know that while adolescence is a develop-
mental period in which peer relations increase in impor-
tance, the importance of relationships with parents and
family does not diminish (Harter, 2012). This potentially
results in additional stress and increases the need for support
for developing adolescents who have selected to continue
their studies in a boarding school environment.
From a purely intellectual standpoint, this culturally
bound phase is figuratively exploding with movement
across vast and various domains of development: from the
biological changes associated with puberty to the social
and emotional challenges of identity consolidation, and
from gains in cognitive and intellectual functioning to an
increased capacity for self-reflection and intimacy in peer
relationships. However, from a relational perspective, ado-
lescents are still in a prime position to be cared for,
affirmed, and mentored toward a full sense of themselves
as emerging adults. Research in the area of resilience indi-
cates the importance of nonparental adult relationships in
the lives of developing youth as a protective factor (Gar-
mezy, 1985; Luthar, Cicchetti, & Becker, 2000; Masten,
2001). In this model, school nurses and counselors work
together to position themselves and the services they offer
to fill this role and meet the needs of their adolescent
students.
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Experiencing Boarding School: A Different Adolescent
Experience
A very small percentage of U.S. families (<.5%) choose to
send their high school students to boarding school, where the
primary mission is to provide a college preparatory aca-
demic experience, which includes residential life (National
Association of Independent Schools, 2013; National Center
for Educational Statistics, 2012). These schools are often
referred to as ‘‘prep’’ (preparatory) schools, a differentiation
from residential schools where the primary purpose is phys-
ical or psychological therapy, such as schools for the blind or
deaf as well as therapeutic schools for students with emo-
tional or behavioral issues. Other types of boarding schools
for adolescents include treatment programs for substance
use, management of problem behavior, military education,
and schools for relocation such as those established in the
past for Native American children.
The reasons for the choice to attend a preparatory board-
ing school vary widely from family to family. For some,
there is a family tradition to follow; for others, a scholarship
may have been awarded for academic/athletic achievement,
presenting a chance to attend a school which offers options
for personal development beyond what local schools provide
(The Association of Boarding Schools [TABS], n.d.;
Gaztambide-Fernandez, 2009). Rollins and Cross (2014)
interviewed senior students at a boarding high school. The
students reported that although they found the school’s aca-
demic challenge required adjustment and created personal
stress, they described their decision to enroll as beneficial
because they believed boarding school helped them to feel
well prepared to begin college.
Attending boarding school can open a host of rich experi-
ences within the traditional model of living and learning in a
residential, all-encompassing setting. The school day blends
into extracurricular activities, followed by communal study,
dining, and sleeping. (TABS, n.d.). Gottlieb (1992) remarks
that unlike adolescents who live at home, boarding school
students conduct most of their lives in collective situations.
Wahab, Rahman, and Nasri (2013), in their study of second-
ary boarding school students, remarked that friends normally
play an important role in any adolescent’s life but especially
so in boarding school where parents are less available.
Although daily interaction with caring adults who serve as
advisors, teachers, and coaches provides supervision and
guidance, there is an inherent need to successfully navigate
peer relationships because of this constant communal life.
Nelson, Kendall, and Shields (2013) closely link the devel-
opment of healthy peer relationships with nurturing adult
care in determining school success and well-being.
Nygren, Bergstom, Janlert, and Nygen’s (2013) study of
school-related determinants of self-reported health among
adolescents, while not specific to boarding school, indicates
that most of the variation in self-reported health was
accounted for on an individual level. Accordingly, health
Pavletic et al.
promotion interventions at school and school health services
should primarily focus on support for the individual students
rather than determinants related to the school itself. This
supports the important role of professionals such as school
nurses or school social workers to whom individual students
can come for help. Students benefit most from school health
services which focus primarily on the students as individuals
with personal differences and concerns, including their rela-
tionships to peers and teachers.
Gottlieb (2001) proposes that students attending boarding
school are different from other high school students in that
they are experiencing a radical and more or less permanent
separation from their homes a full ‘‘developmental epoch’’
earlier than their nonboarding peers. Rather than the tradi-
tional separation upon leaving home for college, the adoles-
cent makes this accelerated transition as a high school
student. The effect of this separation is hopefully helpful
and growth promoting, but can be traumatic and disruptive,
depending upon the particular adolescent and family
involved. The distance between home and school may also
allow for very few visits from family as well as minimized
opportunities for respite at home away from campus life.
Gaztambide-Fernandez (2009) explains that the milieu of
individual boarding schools varies widely in terms of school
culture, mores, educational philosophy, academic rigor, liv-
ing arrangements, boarding versus day enrollment, cultural
and economic diversity, as well as a host of other factors
which may be less tangible, such as unwritten rules and
traditions. While families and admission committees do
their best to predict an optimal fit between admitted students
and the school through school visits, interviews, and review
of test scores and grades, the actual fit may be poor. When
the attributes of the school do not match well with the needs
and expectations of the individual adolescent, it stands to
reason that this poor fit will negatively affect the school
experience and create stress, affecting physical and mental
health. Even the reality of living away from home may feel
very different than anticipated to an inexperienced adoles-
cent. Feelings of homesickness may be overwhelming and
come as a surprise. Fisher, Frazer, and Murray (1986) found
that students new to a boarding school experiencing home-
sickness had an increased incidence of nontraumatic ail-
ments and more class day absences than students who did
not report feeling homesick.
Adolescents from overseas attending U.S. boarding
schools and those who are native-born but not from privilege
or the dominant culture can face additional challenges to
meeting basic health needs. Unfamiliar foods, lack of access
to traditional remedies, inexperience with Western medi-
cine, and cultural mores against asking for help may have
a direct effect on health and seeking care (Rainville, 2013).
In a study of adolescent international boarding students,
Collins (2001) describes the pressure that Asian students,
in particular, report regarding academic success as well as
fear of missing any class time even when ill. Collins further
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3
suggests that providing information and health counseling
relative to health maintenance, and correlating good health
to optimal academic performance can provide an additional
incentive for all students to seek and accept assistance from
campus health services.
International students, students of color, and those not of
privilege may face additional challenges, as adolescents
attending school in a world for which their families may
have little or no frame of reference. Worries about disap-
pointing parents who have sent them to boarding school at
great expense and personal sacrifice in the hope for entry
into an elite college may cause additional concern.
Gaztambide-Fernandez (2009) explains that unlike public
schools or most day schools, athletics and the arts are part
of the required curriculum rather than voluntary. At prepara-
tory boarding schools, participation in extracurricular activ-
ities such as student leadership positions, community
service, and affinity groups is also expected. In families not
intimately familiar with these requirements of engagement,
it can be difficult for students to explain to those at home
why these demands on their time are a daily drain from
concentrated study, especially if their grades in academic
classes are lower than parental expectations.
In considering additional stressors for international stu-
dents, Chow (2011) reports that Asian American and Pacific
Islander students have found that candidates from other eth-
nic backgrounds with comparable academic profiles apply-
ing to the same top tier universities have been admitted,
while they have not been selected. Anecdotally, interna-
tional students at our school have voiced their perception
that there are only so many ‘‘slots’’ for them at the highly
selective universities. Acceptance at an elite university is the
primary goal for many of these expatriated students and their
families, the foundation of the fiscal investment and per-
sonal sacrifice of both students and family (Rainville, 2013).
It is also to be noted that for international students and
students of color, attending a preparatory boarding school
can come with an infrequently cited personal sacrifice. Miss-
ing out on advanced high school coursework in one’s native
language and literature creates a disadvantage in the country
of origin. It may mean that doors of academic opportunity
are closed at home should they decide to return to their
native country prior to earning their diploma in the United
States (Lee, 2011). Students of color or not of privilege may
experience alienation and even be ostracized from family
and community upon return home (Bergin & Cooks, 2002;
O’Connor, 2011).
Health and Attending Boarding School
Managing the day-to-day aspects of self-care such as proper
nutrition and healthy sleep patterns, along with academic,
athletic, and dorm life expectations, can be a struggle for any
adolescent. Nelson et al. (2013) proposes that learning the
organizational skills of time management to be sure
4 The Journal of School Nursing
deadlines are met while negotiating social relationships with
a roommate and other peers can be overwhelming. The ado-
lescent who attends boarding school, rather than living at
home with family, needs to develop a higher level of self-
reliance at an earlier age. Maintaining physical and emo-
tional health can be a difficult challenge without parental
support, intervention, or when advocacy for respite from
commitments is needed.
Independently recognizing the early signs of physical
illness or emotional difficulties and effectively communicat-
ing these troubles is often beyond the capability of an aver-
age teenager. While students who live at home can rely on
parents when they are physically ill, emotionally upset, or
exhausted, boarding school students must rely on the sup-
portive adults at school. As previously presented, communal
living can present its own source of stress as well as increas-
ing the opportunity for infectious illness to spread quickly in
a susceptible population.
A Review of the Literature: Health Services
and Counseling in Boarding School
Because the percentage of the adolescent population in the
United States which attends preparatory boarding schools is
minimal, the corresponding number of school nurses and
counselors who practice in this setting, as opposed to Amer-
ican public or private day school, is also small. For this
reason, it is not surprising that a search of the literature
yielded few related or current works. Database searches
using key terms such as adolescent, health and boarding
school, boarding school and counseling, boarding school and
nursing, as well as boarding school and health services
through PubMed, ERIC, JSTOR, GALE, PsychINFO, and
CINHAL provided few sources. Citations found through
these inquiries most often pertained to Native American
relocation schools and therapeutic schools. Sources specific
to British boarding schools are irrelevant because of the
younger age-group served or the stated purpose of these
schools to remove children from poverty or unsuitable
homes.
Gottlieb (1992, 1998, 2001) reports with frustration that
there is little written about boarding school from the per-
spective of counseling and psychiatry or which addresses the
adolescent experience of this setting. Van Hoof and Hansen
(1999) surveyed 19 New England boarding schools and Van
Hoof et al. (2004) surveyed 11 Connecticut private schools,
6 of which were boarding high schools in terms of mental
health and counseling services. They recommended that
although a collaborative relationship between the infirmary
and mental health services would provide for coordination of
supportive services to benefit students, there were no spe-
cific models to emulate. They also cited the concept of ‘‘in
loco parentis’’ which dictates a responsibility for health care
and mental health resources beyond that of what a day
school assumes. They further proposed that parents expect
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boarding schools to have the professional resources to vig-
ilantly monitor and respond to any physical or mental health
problems in their children, since school adults are responsi-
ble for student well-being while they are living away from
home. A model that provides comprehensive and collabora-
tive care to foster optimal support for the developing ado-
lescent is essential to fulfill this expectation.
Health Services and Counseling in Boarding
School
The typical American preparatory boarding school has a
physical location designated as the campus health services
center, usually comprised of a combined clinic and infirmary
which provides evaluation and care for students when they
are sick, injured, or otherwise unable to function. The clinic
usually has areas designed for assessment and treatment as
well as a dispensary for medication. The clinic often also
functions to arrange and coordinate outside medical appoint-
ments for services not provided by the campus health center
(Magnus, 2014). An infirmary with beds, usually combined
with kitchen facilities and a lounge, provides for rest, recov-
ery, and respite. The infirmary also serves to isolate ill stu-
dents from the general school population in the case of
infectious disease. In many schools, the health services cen-
ter functions as a place for students to stay if they are unable
to attend classes or to meet other commitments due to phys-
ical or emotional issues. Students self-refer to the health
center or are referred by campus adults and parents.
The health services center is usually staffed by nurses,
with a nurse practitioner or medical doctor who is affiliated
or directly employed by the school, to see students and/or
serve in a supervisory/consultant role (Magnus, 2014). The
health services center may also serve as the location for
counseling and mental health services, housing the offices
of professionals on staff at the school, or as a space for
outside providers to evaluate and meet with students. At
some boarding schools, mental health and counseling ser-
vices have separate locations for offices and meeting rooms
from the health services center.
Many boarding schools have a health services center
which is staffed to provide assessment and care for all hours
students are present on campus. Other schools have health
service available by appointment or with health profession-
als available on call (Magnus, 2014). Counseling and mental
health services also vary in immediate availability with sim-
ilar arrangements for regularly scheduled appointments and
emergency on-call availability. Nurses and counselors at
some boarding schools live on campus as residential faculty
with additional campus responsibilities inherent to that role.
The St. Mark’s School Model
At our school, both nursing and counseling services are
housed in the same building on separate floors. The close
Pavletic et al.
Figure 1. An oasis of care: Working relationship between nursing and counseling.
physical proximity between nurses and counselors is an ideal
arrangement allowing for constant communication and reci-
procal referral, but it is our mutually accepted philosophy of
care which is the foundation of our approach to student
health services. As nurses and counselors, it is our centrally
held belief that students seek out the adults at the health
services center for a reason, typically an unmet need which
may or may not be initially clear. Seeking contact with the
helping adults at health services, even without the ability to
verbally articulate the problem, is seen as a form of com-
munication. As illustrated in Figure 1, our health services
center’s unified purpose is to be an oasis of physical care,
emotional support, respite, and developmental nurture for
the adolescents on our campus.
The Health Services Center as a Portal of Entry to Care
As previously stated, adults serve in loco parentis at board-
ing school, which increases the level of responsibility for
student welfare assumed by nurses and counselors beyond
what is required in a day school setting. Wang (2011) further
describes how, by virtue of being far from home, boarding
school students may need comfort and reassurance more
than any medication which could be prescribed. Assessment
of nutrition, stress management, and meeting sleep
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5
requirements takes on increased importance due to the
nature of boarding life and how students are learning to care
for themselves without the presence of family.
Since our health services center is staffed by nurses
around the clock, a student’s initial health services encounter
is usually with a nurse through a drop-in visit to the clinic.
We have a seasoned and consistent staff that the students
come to know well. The nurse welcomes each student within
a setting and framework which closely aligns with the eight
adolescent-friendly care domains as described by Ambresin,
Bennett, Patton, Sanci, and Sawyer (2013). Colorful furnish-
ings, walls hung with student artwork, direct access to cur-
rent heath leaflets on health issues of interest to adolescents,
and a supply of fresh fruit and wrapped breakfast bars fur-
nish the entry and waiting area to the clinic. Students are
greeted immediately and seen as quickly as possible within
an area that allows for privacy and confidential conversation
as needed. Nurses are mindful of the demands of our
school’s daily schedule and expected commitments. We
work with students, teachers, and coaches for reasonable
modifications in expectations and flexibility of deadlines.
Our nurses are friendly, supportive, and consciously
express interest in the student beyond the stated reason of
the visit. Communication with students is characterized by
honesty and confidentiality within the limits of safety and
6 The Journal of School Nursing
school policy. Nurses take the time to be sure students
understand the nature of their condition and corresponding
treatment, and they provide instruction for proper self-care
and offer suggestions for emotional management, such as
relaxation techniques, if needed. As experienced profession-
als, examinations and procedures are conducted with confi-
dence and competence. Lastly, per Ambresin et al. (2013),
we work to be sure students have adequate symptom and
pain relief, referring to outside primary care providers, spe-
cialists, or emergency services when indicated for further
evaluation and treatment. Nurses administer most prescrip-
tion medications in order to ensure compliance and monitor
response to treatment, communicating this response as
needed to prescribers and families.
Admission to the infirmary for recovery from illness,
injury, surgery, or for respite is to a homelike setting.
Dorm-style accommodations, rather than hospital beds, are
made up with quilts. Students have access to a common
room with couches and a television. A full-service kitchen
is stocked with foods that are adolescent-friendly, whole-
some, and easy to prepare. Wireless Internet service allows
students to access the campus network so as to keep up with
assignments. Communication with families is encouraged
through e-mail and phone calls. Faculty and student visitors
are welcome within the confines of the student’s health sta-
tus and need for rest.
With our computer-based software, SNAP Health Center
by Professional Software for Nurses, Inc. (c. 1995–2015),
we are able to identify the frequency of visits by a particular
student and the frequency of presenting complaints in the
population. We are also able to track patterns of illness,
facilitating quick response to upticks in infectious illness
with surveillance and alerts to the community as needed.
Community education is constant. We utilize e-mail remin-
ders about handwashing and other infection control mea-
sures and messages that encourage any ill student to check
in with the health services clinic to receive care and control
infection transmission.
By far, the highest percentage of clinic visits and short-
term infirmary admissions, as per clinic visit tracking, is
rooted in sleep deprivation and exhaustion. It is of historical
interest that Miller (1933) identifies fatigue as the most
common and underappreciated cause of poor success at
boarding school and should be the first area of assessment
when a student’s work or behavior deteriorates. In harmony
with this old but sage advice, a student is admitted for
reparative sleep as an important first step when exhaustion
is directly reported or suspected.
Frequent clinic visitors, especially those with somatic
complaints unsupported by physical findings, are carefully
assessed for underlying psychoemotional concerns. Steven-
son (2010), Shannon and Bergren (2010), Pavletic (2011),
and Boland-Shepard (2012) report that complaints of head-
ache, stomachache, nausea, tiredness, as well as other vague
and variable symptoms may be related to unmet needs of a
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mental, emotional, or behavioral nature, necessitating a
referral to counseling. In a 2013 position statement, The
National Association of School Nurses states: ‘‘Understand-
ing the relationship between frequent health office visits or
somatic complaints as a sign of underlying problems, which
may be organic or psycho-emotional in origin, requires the
unique skill set of the school nurse.’’ The health services
clinic is most often the typical portal of entry for students,
whether the primary concern is physical or psychological in
nature. It is then not surprising to find that 75% of the stu-
dents who were found to join the caseload for regularly
scheduled counseling at our school do so because of an
initial contact with the health center services clinic nurses.
DeSocio and Hootman (2004) recognize health center visits
as valuable interactions through which troubled students
begin to develop a sense of comfort and trust and will ulti-
mately share their worries.
Primary referrals to counseling come from individual
students, peers, families, and school faculty. Our full-time
director of counseling is an experienced, master’s prepared
certified school counselor who sees individual students for
counseling. The director also designs and executes with stu-
dents a formal counseling program of Peer Discussion
Groups, affective education, as well as serving as a resource
when needed for other student centered programs. Our full-
time school counselor is prepared as a Licensed Mental
Health Counselor who also sees students for counseling,
works with student affinity groups, and serves as an active
resource for student programs. Both counselors refer stu-
dents and families to outside providers for evaluation and
treatment as needed. The counselors have youth-friendly
private offices where they meet with students and a comfor-
table conference room to accommodate gatherings.
Communication and Coordination of Care:
A Partnership Between Nursing and
Counseling
The director of health services, the health services nurses,
the director of counseling, and the school counselor commu-
nicate informally about individual students on a daily basis.
This frequent and fluid practice of interaction is the hallmark
of our collaborative model. Both counselors and the director
of health services formally meet weekly with the deans of
students, residential life, academics, and student academic
support, as members of the school’s student support team to
identify individual students who are having difficulty and
may need support and intervention across disciplines. The
American Academy of Pediatrics Committee on School
Health (2004) endorses these multidisciplinary teams in
schools as a best practice for reviewing and planning inter-
vention for students who are experiencing difficulty.
Magnus (2014) surveyed 101 independent school health
services, 29% of which reported having boarding students.
Pavletic et al.
They asked about the frequency of communications by
health services with other school departments. It is interest-
ing to note that of these respondents, only 8 chose counsel-
ing services as one of the most frequently contacted
departments as compared to 128 who chose school admin-
istration and 101 who indicated athletics.
Van Hoof and Hansen (1999) describe the benefits of
formal contact between nursing and counseling not only to
facilitate coordination of care but, more importantly, to con-
nect mental and physical health and treatment. Their exam-
ple of a student who presents with tiredness is diagnosed
with hypothyroidism and then develops depression illus-
trates this connection. Such a case is concretely illustrative
of how a collaborative approach between mental health and
physical health services is necessary and prudent. In their
example, prescribing, administering, and observing the
physical and emotional response medications through blood
work and interaction with the student by the medical and
nursing staff is done in concert with the mental health inter-
vention by the prescribing psychiatrist and treating
counselor.
Designing a continuum of support through collaborative
work by school counselors, school nurses, and outside prac-
titioners ensures that physical, mental health, and social
needs of students are being met. Working together with a
singular agenda utilizes the expertise and talents of individ-
ual professionals for optimal care. This design also benefits
individual members of the care team by providing opportu-
nity for professional support among members, a protectant
against work-related stress and burnout (Clauss-Ehlers,
Serpell, & Weist, 2013; Iachini, Anderson-Butcher, &
Mellin, 2013; Lam, Chan, & Young, 2013; Papa, Rector,
& Stone, 1998; Weist et al., 2012; Weist, Bradshaw,
Lever, & Owens, 2014).
At our school, nursing and counseling meet individually
and as a group with a contracted outside psychologist for
clinical supervision on a regular basis. These individual and
group consultation sessions help us to review our work with
students through the provision of advice and reflection, as
we work with difficult or complicated cases. Clinical super-
vision, by definition, also functions as a supportive space for
our individual and collective professional development
(Lynch, Hancox, & Happell, 2008). Having this consistent
source of professional support and insight is an invaluable
resource in maintaining our ability to optimally work
together as well as in preserving our own mental health.
The case study presented in Table 1 is a simulated repre-
sentation of how our model works with individual students
on a daily basis.
Effectiveness of the St. Mark’s School Model
Our most recent New England Association of Schools and
Colleges Commission on Independent Schools self-study
parent and student surveys related to health services and
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7
counseling indicated high satisfaction with the health ser-
vices and counseling department of the school (St. Mark’s
School, 2011). The parent survey expressed high confidence
and trust that the nurses and counselors were competent,
caring, and communicated well with families about health
issues as they presented in individual students. The surveys
indicate that our students are aware of the resources avail-
able through the health services center and access the center
regularly. In academic year, 2014–2015, 337 of our 364 total
student body have accessed the center at least once. Of our
272 student boarding community, 258 have accessed the
center more than once. Our day students also visit health
services at a similar rate (Table 2).
In review of our 2014–2015 student support team meet-
ing minutes, we see the success of our model evidenced by
several indices: outside referral, improved class attendance,
with decreased numbers of health services visits due to
somatic complaints (Professional Software for Nurses
School Nurse Assistance Program Health Center, n.d.),
improved academic grades as documented through our quar-
terly student academic review process, and resumption of
full participation in the St. Mark’s School program upon
return from formal health leave.
Six students who entered into a counseling relationship
with the school counselors were referred for outside coun-
seling, four of these were then prescribed psychotropic med-
ication. Three students were granted health leave for mental
health concerns in addition to two students who required a
hiatus from school for recovery related to physical health.
Support plans for reentry to school were generated by the
coordinated efforts of nursing and counseling in conjunction
with academic teachers, advisors, dorm faculty, and athletic
staff. All five students were able to either successfully com-
plete the academic year or return in 2015–2016 to repeat the
academic year.
Conclusion and Recommendations
Due to the nature of boarding school life, adolescents in this
setting are learning to care for their physical and emotional
health without the support of home and family. By working
together, school nurses and counselors can provide a caring,
supportive environment for students at school and play a
pivotal role in the promotion of optimal growth and health.
Additional study relative to the role health services and
counseling play in maintaining student health and enhancing
the boarding school experience for adolescents is needed. It
is clear from an extensive search of current literature that
there has been little written on this subject that is applicable
to modern boarding school students and health services. It is
our sincere hope that this descriptive article presenting our
model of health services and counseling generates interest
and inquiry in the provision of high-quality care to adoles-
cents attending boarding school and growing up away from
home.
8 The Journal of School Nursing

Table 1. Case Example: Collaborative Care by Nursing and Counseling.

Student Presentation to Health Services

A 17-year-old senior (sixth form) boarding student from overseas comes to the health services clinic before sports and tells the nurse that
he feels too tired to participate and needs a sports excuse.
When asked about why he might be feeling too tired for sports today, he tells the nurse that he is in the middle of his varsity sports
season and learned a few weeks ago that he was deferred from his first choice college for which he had applied early decision. He has worked
feverishly to complete applications to six other colleges within their deadlines. He has a paper due in English class and has not started it yet.
His voice then cracks and he is on the verge of tears. He hesitantly confides that his mother at home overseas has been diagnosed with
skin cancer and that he is very worried about her. He is acutely afraid that this diagnosis means that his mom is terminally ill. He does not
want his parents to know that he is troubled. This student’s parents speak some English, but the family communicates at home in their native
tongue.

Collaboration Between Nursing and

Nurse/Student Encounter Counselor/Student Encounter Counseling

Nurse ! reassures the student that given the Nursing assessment through student
situation it is understandable to feel encounter ! leads to referral to
overwhelmed, worried, and afraid. counseling.
Exhaustion will exacerbate these feelings.
The nurse performs review of systems,
physical assessment, and all findings are
within normal. The nurse explains to the
student that he is probably sleep deprived,
so he will be admitted to the infirmary for
rest. The nurse talks with the student
about seeing the counselor. He agrees to
see the counselor tomorrow, whom he
knows from his work as a peer discussion
leader
Nurse ! admits the student to the health Counselor ! reaches out to the student to Nurse and counselor ! conference about
services infirmary for rest, contacts his arrange for a time to meet the student’s situation.
sports coach, advisor, and teachers and
informs them that he is in the infirmary for
the night and will not be attending classes
tomorrow. He will need an extension on
his English paper. The nurse plans to help
the student talk with his parents
tomorrow after resting to gain a better
understanding of his mom’s health status
and to enlist their support.
Nurse ! contacts counselor and gives an Counselor ! meets with the student after he Counselor and nurse ! talk with the student
update on the student awakens around noon the next day and and his sister about his concerns. The
finds that he feels much better but has student’s sister is supportive and also
been having trouble focusing on classes concerned about her brother. She
since learning about his college deferment convinces him that it would be best for the
and has fallen behind in his schoolwork, counselor and nurse to talk directly to the
especially English. The student continues parents and that she would act as
to be reluctant to call his parents but does interpreter
agree to have the nurse and counselor talk
with his 22-year-old sister, who is a college
student, and speaks English.
Counselor, nurse ! work with the school’s
technology experts to arrange a face-time
conversation with all involved
(continued)

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Pavletic et al. 9

Table 1. (continued)

Collaboration Between Nursing and

Nurse/Student Encounter Counselor/Student Encounter Counseling

Counselor, nurse, student ! call the

student’s parents and with his sister’s help,
they were able to learn that their mother is
doing very well. She had surgery to remove
a lesion but has not required radiation or
chemotherapy. The student is able to
actually see his mother and feels relieved.
The parents communicate that they are
concerned about their son but also feel
reassured that he has caring adults to help
him
Nurse! knowing that most adolescents turn
to the Internet for information, the nurse
helps the student to access accurate
information pertinent to his mother’s
condition from reputable medical websites
Counselor ! arranges another appointment Counselor and nurse ! present this
with the student to continue a counseling student’s case to the student support
relationship for follow-up and emotional committee within the confines of
support as needed confidentiality

Table 2. St. Marks School. American Academy of Pediatrics. (2004). School based mental
health services. Pediatrics, 113, 1839–1845.
Health Services—Student Access Data 2014/2015
The Association of Boarding Schools. (n.d.). Discover boarding
Student Total # Student Visits school: The fine print. Retrieved April 29, 2015, from http://
Population Students (≥ 1) Percentage www.boardingschools.com/discover/fineprint.aspx
Bergin, D. A., & Cooks, H. C. (2002). High school students of
Total enrollment 364 350 96
color talk about acting white. The Urban Review, 14,
Boarding 272 258 95
students 113–134.
Day students 92 69 75 Boland-Shepard, S. (2012). The role of school nurses in the early
identification, referral and provision of services for students
with early signs of mental, emotional or behavioral disorders:
Acknowledgments A dissertation. Unpublished doctoral dissertation, University of
The author would like to gratefully acknowledge the editorial assis- Massachusetts Medical School Graduate School of Nursing,
tance of Margaret E. N. Caron and David Lubick, English Depart- Worcester, MA.
ment, St. Mark’s School, Southborough, MA as well as Maureen Chow, G. (2011). Asian American and Pacific Islander. Indepen-
A. Jones, BA, MN, RN, Framingham Public Schools, Framingham. dent School Magazine. Retrieved from http://www.nais.org/
Magazine-Newsletters/ISMagazine/Pages/Asian-Americanand-
Declaration of Conflicting Interests PacificIslander-AAPI.aspx
The author(s) declared no potential conflicts of interest with respect Clauss-Ehlers, C. S., Serpell, Z. N., & Weist, M. D. (Eds.). (2013).
to the research, authorship, and/or publication of this article. Handbook of culturally responsive school mental health:
Advancing research training practice and policy. New York,
Funding NY: Springer Science and Business Media.
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Author Biographies
Adria C. Pavletic, MA, MN, RN, NCSN, is the director of Health
Services at St. Mark’s School, Southborough, MA, USA.
Thomas Dukes, MSW, MS, EdD, is an associate professor and the
director of School Counseling Graduate Program in the Department
of Counseling, Educational Leadership, and School Psychology at
Rhode Island College, Providence, RI, USA.
Jamelle Gardine Greene, PhD, is a licensed psychologist at Pri-
vate Practice at Framingham, MA, USA.
Jennifer Taylor, MA, CAGS, is the director of counseling at St.
Mark’s School, Southborough, MA, USA.
Louise B. Gilpin, LMHC, is the school counselor at St. Mark’s
School, Southborough, MA, USA.