Listening and learning: By monitoring signs of psychosocial distress, Janice Daniels (at left) and Sandra Leonard are changing the lives of their teenage patients.

Crying inconsolably, the 16-year-old girl slowly managed to tell her story to Emory nurses Janice Daniels, 95MN, and Sandra Leonard, 96FNP, who oversee the Adolescent Health Station at Atlanta's Booker T. Washington High School.

The teen, they learned, was in mourning, and had been for months. Unable to visit her mother as she lay terminally ill in the hospital and not allowed, when the time came, to attend the funeral, she had never really been able to say goodbye.

The two Emory nurses encouraged the girl to talk about her loss. They learned she had no photographs of her mother. They also learned that her mother had attended Booker T. Washington in the 1970s. Acting on inspiration, they found a picture of the woman in an old yearbook, had the photo enlarged and framed, and gave it to the girl.

"She went from sobbing to glowing," recalls Leonard. "She showed that picture to everyone and was finally able to work through her grief. Now she seems to be doing fine."

"Her father simply had not understood how much pain his daughter was carrying around," says Daniels. "When he was made aware of the grief, it turned out to be a healing experience for the whole family--the girl, her little brother, and the father."

A profound, positive impact

Leonard and Daniels, it seems, are not your typical school nurses.

Instead of aspirin and Band-Aids, they provide a safe and comfortable environment where Booker T. students can discuss anything that concerns them (while another full-time nurse provides traditional clinical services). The pair admit that some health professionals don't understand how their psychosocial work fits into the scope of nursing.

"That's sad," says Daniels, "because this kind of nursing can have a profound, positive impact on health. People hear about the health station and are quick to ask, 'So what do you do about teen pregnancies, drugs, violence?' But those are symptoms. Our work is to reach these kids before they get to that level of distress."

A symptom-distress approach is what drives the health station--the idea that adolescents experience negative thoughts, tension-filled interactions, and anxious feelings which can be identified and dealt with long before that distress turns into full-blown physiological and psychological crises.

"We try to be a support, to let these kids know they have choices," says Daniels. "We can't change where they live, or their mother's or father's behavior, but we can help them build self-esteem and learn negotiating and coping skills."

Talk, listen, and observe

The Adolescent Health Station at Booker T. Washington opened in January 1996 after Leonard and Daniels had spent months conducting a detailed needs assessment of the high school, the largest in Atlanta. The health station's mission-- to deliver psychosocial services at an on-site location--is backed by a five-year commitment from the School of Nursing.

"We didn't march into the school loaded with fixed concepts and programs," says Daniels. "We learned early on that to succeed we must talk to people, that we must listen and observe."

Nursing school Dean Dyanne D. Affonso notes that the conceptual organization of the health station is similar to that of her Malama project, which relies on community input to find solutions to problems facing pregnant women.

"What we do at Booker T. Washington," she says, "is ask, 'What is needed to enable you to take charge of your health?' It's addressing what the teens say are priorities--and not dismissing those things because they don't meet diagnostic criteria."

Absenteeism and grief

In order for the program to work, Daniels and Leonard knew they needed the support of teachers, administrators, and the youth themselves. In addition to teaching occasional health classes at the high school, covering topics that ranged from sexually transmitted and communicable diseases to CPR, they also began attending faculty meetings. Time and again at these meetings, they heard about high absenteeism at the school.

"According to class attendance records, 25% to 30% of the students were absent daily," says Leonard. "The problem was most pronounced in the first year of high school. Of 600 ninth-graders, 200 or more were absent virtually every day."

Moreover, the Emory nurses learned that in recent years 49% of ninth-graders, on average, dropped out of school and never entered tenth grade. Alarmed, Leonard and Daniels approached the school about developing programs that would specifically target ninth-graders.

"Something was going on in the transition from eighth to ninth grade, from middle school to high school, that was keeping these kids from making it," Leonard says. "We met with the teachers and told them that if they had a couple of kids in their ninth-grade homerooms they felt could use some extra support, to send them to us. We ended up with a nice group to begin working with."

As the Booker T. students began to open up to them, Daniels and Leonard discovered one of the reasons many were skipping school.

"They had issues of grief," says Daniels, who, with Leonard, has now worked with about 300 students. "We learned that a lot of children in our population have five or more relatives or close friends who have died violently. As a result, many of them feel hopeless, that they will die young, that there is nothing to strive for."

That point was dramatically emphasized when a Booker T. Washington tenth-grader was killed last year in a drug-related shooting just blocks from the school. Daniels recalls how teens stood in the hallways, shocked and tearful.

"Most of these youngsters had been in school with that boy for two years," she says. "Some went to middle and elementary school with him. How do you deal with that?"

They dealt with it quickly. Using the school intercom, the nurses invited anyone who knew someone who had died a violent death to a discussion the next day. "We were overflowing with kids," Leonard remembers. "At least 250 came. They stood up and talked about this death, and past deaths, what violence meant. It triggered emotions that needed expression."

Helping the community take care of its own

Daniels and Leonard draw on resources from Emory and the community at large to help facilitate special programs at the health station. For example, Bernadette Leite, a behavioral specialist at the Rollins School of Public Health at Emory, regularly conducts workshops on grief. Rape counselors from Grady Hospital lead discussions with teen girls on defining good and bad relationships, date rape, self-protection, and where to get help if raped or molested.

Parents are frequently invited to participate in programs. Last fall, Daniels and Leonard held a heavily attended mother/daughter conference. They plan to hold another this year. "We want to help mothers understand," Leonard says, "that if they don't take the time to make their daughters feel special and loved, the girls will seek that attention elsewhere--and the choices aren't very good."

Daniels and Leonard are adamant that no strict line demarcates their work at Booker T. Washington from the rest of the community.

Noting that the high school draws students from five public housing areas in Atlanta, Daniels and Leonard are exploring ways they can cooperate with housing management to help the community. For instance, Harris Homes parents have been recruited to help monitor school hallways. Once they are on board for the parent patrol, they are encouraged to participate in health screenings. Those lacking high school diplomas are guided to enroll in Booker T.'s night school.

Emory graduate nursing students also volunteer at the health station, which has been designated as an alternate clinic site for independent study.

"One of the nursing school's requirements is that a student must give back to the community by designing and carrying out a project," Leonard says. "One student went to various housing projects and worked with tenant leaders to get parents to attend PTA meetings."

"The more closely we are able to work with people in the community," says Dean Affonso, "the more we in nursing are helping the community take care of its own."

Listening to distress

Leonard and Daniels are currently developing research based on data from their records of student visits to the health station, the types of issues discussed, and the information requested. They are convinced their symptom-distress model of care has broad applications.

"Yes, this is a predominantly African-American high school," says Leonard, "one in a lower socio- economic area. And there are issues that are culturally specific--different cultures may express symptoms and distress differently from the dominant culture, and health care workers need to be sensitive to that. But we think this model would also work in a more affluent area. These are adolescent-specific, universal concepts that cut across socio-economic and racial grounds."

Daniels agrees. "Whether your mother is working three jobs and struggling to make ends meet," she says, "or your mother is a CEO and you live in a mansion, if you're feeling unwanted and unloved, if no one is listening to your distress and helping, the outcomes are similar."

Reprinted from Emory Nursing, Spring 1997

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