The Journal of School Nursing2023, Vol. 39(6) 496–505© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI:10.1177/10598405211043872journals.sagepub.com/home/jsn
Chronic absenteeism is associated with poor health and educational outcomes. School nurses have great potential to address the health and educational needs that contribute to absenteeism. Through qualitative analysis of interviews with school nurses, we characterize their current role in reducing absenteeism and identify barriers 3 that limit their capacity to meet this goal, organized by the Framework for 21st Century School Nursing Practice. Interviewees (n = 23) identified actions perceived to reduce absenteeism aligned with domains of care coordination, leadership, quality improvement, and community and public health. Barriers perceived to limit the capacity of school nurses to address absenteeism were identified within these domains and ranged from student- and family-level to federal-level barriers. Specific healthcare system-level barriers included insufficient communication with community-based healthcare teams and the need for coordinated approaches across health and education sectors to address absenteeism. Strategic opportunities exist to address barriers to comprehensive school nursing practice and reduce absenteeism.
Keywordspediatric, adolescent, school health, school nursing, absenteeism
Chronic absenteeism, defined as missing 10% of school days, impacts over 7 million U.S. students with bidirectional effects on their health and education (U.S. Department of Education, 2018). Chronic absenteeism is linked to poor educational outcomes including grade failure and drop-out (Balfanz & Byrnes, 2012), and lower educational attainment in youth predicts worsened health in adulthood including higher rates of cardiovascular disease, type 2 diabetes, and depression, and increased overall mortality (Kubota et al., 2017; Mezuk et al., 2008; Muennig et al., 2010; Rogot et al., 1992). Additionally, childhood health problems are leading causes of absenteeism and poor academic outcomes (Akinbami et al., 2010; Allison & Attisha, 2019; Basch, 2011). Populations with poor access to medical care and exposure to socio-structural disadvantage experience disproportionate rates of absenteeism and its negative sequelae (Kimbro et al., 2008; Stempel et al., 2017; Zhang, 2003). To achieve health and educational equity for all students, new approaches are needed to reduce chronic absenteeism and address underlying disparities in health and health care.
The over 130,000 practicing school nurses nationwide are health professionals, who are well positioned at the interface of health and education and have great potential to meet the interrelated health and educational needs that contribute to chronic absenteeism (Willgerodt et al., 2018). In existing research conducted at the individual school or school district level, health care delivered by school nurses has been associated with improved health status in children with chronic medical conditions, fewer missed school days, and superior academic outcomes (Best et al., 2018; Lineberry & Ickes, 2015; Maughan, 2003; Yoder, 2020). Beyond direct care delivery, school nurses possess the skills, education, and training needed to reduce chronic absenteeism through their historically underutilized roles as community health leaders and public policy change makers. The National Association of School Nurses (NASN) emphasizes this full scope of today’s school nursing practice in their Framework for 21st Century School Nursing Practice, which delineates the role of school nurses in the non-hierarchical, overlapping domains of care coordination, leadership, quality improvement, and community and public health provision, each of which is encircled and supported by standards of practice (NASN, 2016). Few studies have evaluated the impact of school nursing practice across these domains on academic outcomes (Best et al., 2018) and even fewer have rigorously tested school nursing interventions aimed to reduce absenteeism as a primary outcome, a critical area of study identified as a 2020–2021 NASN Research Priority (Bergren, 2021).
Realizing the full potential for school nurses to address chronic absenteeism requires identification of specific strategies to support school nurses in promoting attendance across all domains of the Framework for 21st Century School Nursing Practice. In general, the ability of school nurses to provide comprehensive health care for a population of students with increasingly complex medical needs (Knauer et al., 2015) is hindered by large caseloads, inadequate data systems, limited communication with community health care providers, and unmet needs for advanced leadership and public health training (Endsley, 2017; Quaranta & Spencer, 2016; Ravenna & Cleaver, 2016; Stock et al., 2002). To guide work specifically supporting school nurses in addressing chronic absenteeism and to inform school nursing intervention development, we require a more nuanced understanding of barriers that school nurses experience when working to promote attendance among their students.
To address this knowledge gap, we aimed to characterize school nurse perceptions of their role in promoting attendance and identify strategies to bridge the gap between current school nurse practice and potential to address chronic absenteeism by describing potentially modifiable barriers across multiple levels related to the student or family, school or school district, state or federal government, and the health care system. Through qualitative analysis of semi-structured interviews with school nurses who care for high-school students—an age group where rates of absenteeism traditionally peak (U.S. Department of Education, 2018)—we describe the perceived role of school nurses in reducing chronic absenteeism and the barriers they face in their work to achieve this goal. As a result, we present a series of actionable solutions organized within the Framework for 21st Century School Nursing Practice by their potential to support the role of the school nurse in care coordination, leadership, quality improvement, and community and public health provision toward the goal of increasing the capacity of school nurses to reduce chronic absenteeism.
We examined the perspectives of nurses who work with highschool students in Allegheny County, Pennsylvania, through the qualitative analysis of semi-structured phone interviews. This analysis focused on roles, barriers, and facilitators in addressing chronic absenteeism. Allegheny County includes a large metropolitan area and surrounding suburbs in southwestern Pennsylvania and is the second most populous county in the state with approximately 1.2 million residents. Allegheny County contains 43 school districts serving 144,520 students grades K-12 with 276 public schools, including 59 public high schools. There are approximately 177 full-time and seven part-time certified school nurses assigned to these schools with an average caseload of 921 students each. On average, Allegheny County public schools report 16% of students and 24% of high-school students are chronically absent. Local rates of chronic absenteeism are similar to national rates, indicating chronic absenteeism among approximately 16% of all students and 21% of high-school students (U.S. Department of Education, 2018).
Certified school nurses working in public schools in Allegheny County who served any students in grades 9 to 12 were eligible for participation. To guide purposeful sampling at the school level, we utilized existing data collected through the 2014 Healthy Allegheny Teens Survey (HATS), a random digit dial phone survey of 1813 high-school-aged youth in Allegheny County evaluating factors relevant to their health and education (Allegheny County Health Department, 2014). HATS data were aggregated at the school level to identify average student-reported health status and school connectedness. School nurses were sampled from schools with high and low student-reported health status and school connectedness, two factors previously associated with absenteeism. School nurses (n = 56) were notified of the study by the study team or a community liaison via email, phone call, and/or in person recruitment at continuing education events.
We developed the interview guide through an iterative process informed by the NASN Framework for 21st Century School Nursing Practice and the Consolidated Framework for Implementation Research (Damschroder et al., 2009). We refined the interview guide through discussions with stakeholders including school nurses (n = 3), general pediatricians (n = 2), and community health liaisons (n = 2), and pilot interviews with school nurses (n = 3). Interview guide questions included the current and ideal role of school nurses in addressing absenteeism, barriers and facilitators to addressing absenteeism, and key internal and external supports. Specific questions probed about potential solutions to enhance the ability of school nurses to address absenteeism through collaborative school nurse–community health partnerships. A copy of the interview guide is provided in Appendix 1.
Interviews were conducted by two investigators trained in qualitative data collection. After obtaining verbal consent, interviews averaging 30–45 min were conducted by phone, audio-recorded, and transcribed. Participants received $20 gift cards. Interviews continued until thematic saturation, (Guest et al., 2006), which occurred with the application of the last new code related to chronic absenteeism in the 18th interview. Interviews were conducted from February 2019 to January 2020.
Audio-recordings were transcribed verbatim, with identifying information removed. Transcripts were analyzed using thematic content analysis (Ryan & Bernard, 2000) to first identify broad themes and then differentiate subthemes. Two investigators independently coded each interview. A provisional codebook was developed based on coding of the first five interviews and reviewed with the senior investigator. Interviews were then coded by the two investigators, compared for agreement after every 5 coded interviews, and finalized through consensus, with the codebook updated throughout the coding process to reflect emerging themes. Coding was performed using Dedoose 8.3.17 (Los Angeles, CA) (Dedoose, 2020).
At the conclusion of coding, we performed an additional member checking step to increase the trustworthiness of our results. We reviewed themes and subthemes with school nurse stakeholders (n = 3) from the Pennsylvania Association of School Nurses and Practitioners and refined based upon their feedback. Specifically, this helped to clarify themes related to interactions between school nurses and community-based health care providers surrounding absenteeism.
The University of Pittsburgh Human Research Protection Office deemed this study exempt from Institutional Review Board approval.
We conducted interviews with 23 high-school nurses (Table 1). A total of 10 nurses held bachelor’s degrees, and 13 nurses held master’s degrees. Three of the master’s-level nurses were also certified nurse practitioners. While some nurses were assigned to kindergarten to 12th grade, nearly half worked specifically at schools including only grades 9 to 12.
Interviewee perspectives on their current role addressing chronic absenteeism, and barriers that limit their capacity to maximally address chronic absenteeism spanned the four nonhierarchical domains of the Framework for 21st Century School Nursing Practice: care coordination, leadership, quality improvement, and community and public health provision. Representative quotes are provided in Appendix 2.
Interviewees identified four care coordination activities of school nurses perceived to reduce absenteeism (Table 2). First, they perform direct care such as providing care for acute issues to prevent early dismissal from school, managing chronic conditions, and referring to community resources for additional treatment or support:
I think that we have a major role in helping decrease absenteeism. Again, through education, through medication administration, through diabetic management… We can develop management plans, work with those students, help them to just live normal lives and be successful in school, because they’re medically managed well, and they feel so much better.
Second, school nurses coordinate care by engaging directly with students and families to prevent absenteeism. This includes building supportive relationships with students who seek their care to understand and address their unique health and educational needs and to identify emerging medical problems which may contribute to absenteeism. Third, school nurses provide case management to students experiencing problematic patterns of absence. This includes providing focused support to students struggling with absenteeism and developing individualized medical absence action plans to improve their attendance. Fourth, school nurses perform care coordination with community-based health services including working with primary care physicians (PCPs) to promote attendance.
Interviewees also identified numerous barriers which limit school nurse capacity to reduce absenteeism through care coordination, which fell into four categories across four levels (Table 3). First, they identified barriers which contribute to high demand for low acuity direct care and limit the other vital roles of the school nurse. These include high student to school nurse ratios and school staff misunderstanding of when to send students to the school nurse:
The law is one certified school nurse to every 1500 students… That’s where I see a difficulty. We could do a lot. We know how to do a lot. Part of our education is we straddle healthcare with school law. The numbers are a big barrier in us doing as much as we could do.
Second, interviewees identified barriers to care coordination related to insufficient interdisciplinary school-based approaches to absenteeism and called for team-based approaches including school nurses, guidance counselors, teachers, and school administrators. Third, they identified barriers limiting health information sharing including lack of access to students’ community-based medical records and lack of parental permission to share information with community health providers, either due to parents’ unwillingness to grant this consent or inefficient methods of obtaining releases from parents. Fourth, they identified limitations to care coordination between school and community health providers, specifically PCPs, within three subthemes. The primary subtheme identified a lack of mechanisms to allow school nurses to alert PCPs of concerns including emerging medical concerns, worsening chronic conditions, unmet school requirements that may lead to medical exclusion from school, and excessive school absences. The secondary subtheme identified a lack of mechanisms to allow PCPs to relay information to school nurses about needed educational accommodations for students, instructions for care of chronic conditions at school, post-injury or illness plans of care, orders for school medication administration, and reasons for medical absences and time of expected return to school.
A student might be seen and they’re told they can return to school on such and such a day, and they return three days later. If we knew they were told they could be at school the next day, we can follow-up and say, “Hey, how’s it going? When do you plan on returning to school? What is preventing you from coming to school?”
The final subtheme hindering care coordination across school and community health settings identified a lack of guiding principles for coordinated school and community health approaches to reduce absenteeism. Specifically, interviewees identified a need to establish unified guidance on appropriate return to school following acute illness, avoidance of providing or accepting blanket or retrospective medical excuses, and routine inquiry about academic performance and absenteeism in medical settings.
Interviewees saw opportunities to intervene on absenteeism within the domain of leadership in two ways. First, school nurses advocate for the medical and educational needs of their students. Second, they serve as leaders within their schools in both formal and informal roles by serving on school-based attendance teams, contributing to school attendance policy decision making, and enforcing school attendance policies. Interviewees specifically felt that they were critical in enforcing policies around appropriate early dismissal or absence due to medical reasons:
Now, keeping the kids in school is what I’m involved in. We have a protocol that says kids are sent home for fevers and actively vomiting. It’s up to my judgment to decide whether a kid needs to go home or not.
Barriers to acting as leaders to address absenteeism fell within three categories. First, interviewees identified limited leadership capacity due to a lack of clear school attendance policies for preventing and responding to absenteeism and for early dismissal from school for medical reasons. Second, interviewees expressed that school nurses are not always recognized as leaders and often instead perceived by school administrators or staff as capable of only direct care provision for minor injuries or illnesses:
I think they’re finding out now, or coming to the realization, that we don’t just put on Band-Aids and hand out medicine like candy, but that we’re actually doing things. That we’re here to help facilitate the child’s education… I think if people would actually trust us and our expertise, I think things would go a lot better.
Third, interviewees identified a need for continuing education for school nurses to advance their leadership abilities toward reducing absenteeism, specifically training around mental health care and responding to substance use.
Interviewees identified two ways that school nurses address chronic absenteeism through quality improvement activities. First, they collect and interpret data, specifically attendance data and data related to school health requirements to prevent school exclusion due to noncompliance. Second, school nurses utilize data to drive intervention by identifying students with excessive absence who require intervention and by leveraging attendance data to educate and intervene for these students:
A lot of times I’ll have the kids look right over my shoulder… I say, “Come look at this. Your attendance has been terrible.”… Then I’ll call parents too. I’ll say, “Listen. I just had a discussion with your son. He is back in class right now, but he’s already missed 16 days of school.”
Barriers identified as limiting school nurse capacity to address chronic absenteeism through quality improvement each related to challenges accessing data. Interviewees identified a lack of access to attendance data within their own schools as a barrier to intervening early and effectively in cases of extended or repeated absence:
I had one kid who was—he wasn’t coming to me as the nurse. He was going to the person who does early dismissal. I got a call out of the blue from his health provider who had said that he had missed 15 days of school… Because I hadn’t been involved with that person in going home and the reason, I wasn’t able to get in front of that.
Interviewees also reported a lack of access to medical absence excuses and academic data as limits to their ability to identify and address any medical problems that may contribute to absence.
Within the domain of community and public health, interviewees identified two ways that school nurses reduce absenteeism. First, they provide health education, specifically educating students and families on medical concerns which should or should not keep a student home from school. Second, they lead school health promotion efforts by implementing school-wide interventions to promote mental health and wellness and to meet educationally relevant health needs.
Interviewees identified barriers which limit their capacity to address absenteeism through community and public health provision related to two themes. First, interviewees felt unable to adequately address the mental health needs of their student populations due to insufficient school support staff with mental health expertise and unmet needs for integrated school-based mental health care. In the absence of these services, some school nurses felt taxed to provide school-based therapy alone or with insufficient training, especially in light of challenges faced by students in accessing limited community-based mental health services. Second, interviewees identified the lack of school nurses in every school every day as a limit to the broader capacity of school nurses to address absenteeism from a community and public health perspective:
Recently our superintendent put a nurse in every school, so I do think that helps. … Before the school didn’t have that, so parents really didn’t have anywhere else to turn.
Through qualitative interviews, we characterized the perceived role of school nurses in addressing chronic absenteeism and identified barriers which school nurses experience in this role. School nurses clearly recognized their pivotal role in addressing chronic absenteeism and perceived broad potential to reduce absenteeism through care coordination, leadership, quality improvement, and community and public health provision. Importantly, interviewees identified needed supports at the community, school, district, state, and federal levels, as well as health care system interventions, which may increase capacity of school nurses to address chronic absenteeism.
Prior studies exploring the impact of school nursing activities on attendance rates have mainly focused on direct care provision by school nurses towards infection prevention (Kimel, 1996; Morton & Schultz, 2004; Wiggs-Stayner et al., 2006), treatment of acute concerns to prevent early school dismissal (Allen, 2003; Foster & Keele, 2006), and school-based care of students with asthma (Harrington et al., 2018; Levy et al., 2006; Moricca et al., 2013; Trivedi et al., 2017), activities also perceived to be important by school nurses in our study. In contrast, activities perceived to reduce absenteeism in our study spanned all domains of the Framework for 21st Century School Nursing Practice and included methods of primary prevention (e.g., providing universal health education for students and families), early identification (e.g., tracking frequent visits to the school health office to identify emerging medical needs), and secondary intervention once problematic attendance patterns develop (e.g., developing medical absence plans). Although interviewees detailed many of these efforts as informal day-to-day activities of school nurses, the actions described conform strongly to components of more formal approaches of multi-tiered school-based interventions to reduce absenteeism (Attendance Works, 2018a, 2018b; Kearney & Graczyk, 2014). Our findings display that school nurses are not only aware of their role in addressing absenteeism, many are already implementing multiple strategies to help improve attendance. Formalizing the role of school nurses in interventions designed to reduce chronic absenteeism at the child and school level appears to be a key next step.
Notably, although school nurses perceived a role in promoting attendance across all domains of the Framework for 21st Century School Nursing Practice, they most frequently identified care coordination as an integral mechanism through which they may reduce chronic absenteeism. The primacy of care coordination to address chronic absenteeism is supported by substantial evidence for the effectiveness of school-based health centers—a model of coordinated, school-located primary care—in improving attendance (Knopf et al., 2016). However, school-based health centers reach only about 3% of U.S. students through on-site services and 10% through off-site school-linked services (Love et al., 2019). In contrast, over 80% of schools have a full- or part-time school nurse (National Center for Education Statistics, 2020), emphasizing the importance of school nurse-led or partnered interventions to broadly reduce chronic absenteeism. To allow school nurses to maximally intervene to reduce chronic absenteeism, multilevel supports are needed to address the identified barriers to optimal school nursing practice.
At the school or school district level, a key first step to reducing chronic absenteeism through school nursing practice is to advocate for school nurses to routinely be included as integral members of school attendance teams. School leadership, school staff, school nurses, and other school health or mental health personnel should work together to develop attendance policies and enact collaborative team-based approaches to absenteeism. School nurses can bring their unique expertise to these teams to ensure that absenteeism is recognized as a complex phenomenon caused by interacting health, academic, family, school, community, and structural factors (Allison & Attisha, 2019). As members of school attendance teams, school nurses can work to address the multifactorial causes of absenteeism through partnerships with community health and mental health providers and youth-serving community organizations. Additionally, schools should recognize attendance data as health data and grant school nurses timely access to attendance records and medical absence excuses. This will allow school nurses to more rapidly identify students with emerging medical concerns or poorly controlled chronic conditions, which contribute to absenteeism. For students with identified health needs, school nurses can utilize an Individualized Healthcare Plan to outline school nursing interventions guided by the Framework for 21st Century School Nursing Practice toward the goal of optimizing student health and attendance (NASN, 2020a).
At the state or federal levels, policies that support school nurses in every school every day and limit student to school nurse ratios are needed. Importantly, a standard student to school nurse ratio cannot adequately determine optimal staffing for safe care (NASN, 2020b). Instead, appropriate staffing should be determined after careful consideration of the student population’s health needs and social influences on health, which may manifest as disparities in health and academic outcomes including chronic absenteeism. Increasing the availability of school mental health providers will also be a valuable way to support students and reduce clinical burden for the many school nurses who are currently filling this role. Adequate time and appropriate support staff are key prerequisites to school nurses’ effective engagement in activities proposed to reduce chronic absenteeism.
At the health care system level, school nurses should be considered part of the larger community health team for children and adolescents. To keep students healthy and in attendance, strategies are needed to enhance communication between school- and community-based health practitioners as well as other community partners engaged in housing stability and safety, food security, and social services. Local solutions may include encouraging PCPs to routinely obtain permission for information sharing and identify school nurses as care team members. Larger structural solutions may include shared electronic health records between school and clinical settings. Efforts should be taken to responsibly design and rigorously study such system-level interventions to determine the value and outcomes of coordinated school and community health partnerships. The health care system additionally bears responsibility to ensure that professional development for school nurses keeps pace with students’ increasingly complex health needs. Schools of nursing, school nurse certifying bodies, and the NASN should have shared roles in school nurse training and continuing education, including related to needs for leadership development identified in this study. Related to identified needs for mental health training, approaches that partner with other medical organizations to draw on interdisciplinary expertise (e.g., American Academy of Child and Adolescent Psychiatry) or engage school nurses to identify emerging needs and tailor education (e.g., the Mental Health Training Intervention for Health Providers in Schools (Bohnenkamp et al., 2019)) may be particularly beneficial.
Finally, school nurses described cross-cutting issues related to data access and health information sharing that are currently limited by complex and multilevel barriers. School nurses described school-level barriers to accessing academic and attendance data and acknowledged larger barriers to accessing and sharing health information at healthcare system, state, and federal levels. School nursing activities may be at times subject to the Health Insurance Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act (FERPA) (U.S. Department of Education, 2019) which was seen as a source of confusion that often led community health care providers to restrict health information sharing with school nurses despite appropriate permissions. Further, they described time-consuming methods of nurse-led data collection without formal systems for data tracking and with poor integration across health and education domains at both the school and community levels. To alleviate barriers to data access, multilevel support is needed for efforts to standardize school nursing data collection and build consolidated health and education data repositories. Working partnerships between schools and local health systems or academic institutions may support these goals and better equip school nurses with the resources needed to translate data into continual quality improvement initiatives. To support health information sharing, efforts are needed to integrate school and community electronic health records and clarify restrictions on health information sharing between school and community health teams. In these ways, we may both lift undue administrative demands on school nurses to allow them to work to the full potential of their role and enhance school and community health care coordination. Additionally, health and education data integration and transparency will allow for monitoring as we work toward goals of more equitable distribution and quality of school nursing services and build evidence for the impact of school nursing services on individual and population-level academic and attendance outcomes.
Our study has several limitations. First, we interviewed a subset of school nurses from a small geographic area which may limit the generalizability of our findings. Specifically, the school nurses interviewed represent high schools in primarily urban and suburban school districts. While absenteeism commonly peaks among high-school students, patterns of absenteeism are established as early as kindergarten and school nurse-led approaches to reduce absenteeism may differ in younger age groups. Chronic absenteeism similarly affects all geographies, but contributors to poor attendance and optimal interventions may differ in rural areas. However, within our defined sample, we sought to maximize the heterogeneity of school nurses’ experiences by sampling on student-reported health status and school connectedness. Second, as a qualitative study, our results should be viewed as exploratory. Our study aimed to identify a broad range of actions perceived by school nurses to support their role in reducing absenteeism. We did not aim to rank the relative priority or feasibility of these actions. Further work should assess the relative importance of these approaches toward increasing the capacity of school nurses to address chronic absenteeism.
Chronic absenteeism is an important public health issue. School nurses are health providers embedded within schools who are ideally positioned to support the management of interrelated health and educational factors which contribute to chronic absenteeism (NASN, 2018). School nurses have a documented ability to improve attendance through direct care delivery (Best et al., 2018; Maughan, 2003), and possess yet unstudied potential to more significantly reduce chronic absenteeism through school nursing activities and formal nurse-led interventions spanning all domains of the Framework for 21st Century School Nursing Practice. School nurses can continue to impact chronic absenteeism through their clinical roles in care coordination, quality improvement, leadership, and community and public health provision and through advocacy toward eliminating the identified barriers to these activities.
We identified a range of school nursing activities, which interviewees perceived to reduce chronic absenteeism and barriers that limit these activities. Future quantitative work should assess the impact of these activities on absenteeism, including among populations who experience both higher rates of absenteeism and disparate effects of absenteeism on their future health and educational outcomes. Our findings may also inform the design, implementation, and evaluation of school nurse led or partnered interventions aimed to reduce absenteeism. Specifically, future research should quantify the impact of school nursing services beyond direct care, including those related to other components of care coordination, leadership, quality improvement, and community and public health provision, on measurable academic and attendance outcomes. Finally, we identified actionable solutions to increase the impact of school nurses through cross-sector collaboration and multilevel strategic approaches necessitating community, school, district, state, and federal partnerships to support school nurses in realizing their ideal roles in reducing chronic absenteeism and ensuring health and educational equity for all students.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the National Institutes of Health (T32HD087162, T32HD071834), by the Health Resources and Services Administration (T32HP22240), and by an Academic Pediatric Association Resident Investigator Award (Rankine).
Jacquelin Rankine https://orcid.org/0000-0002-8072-6762
Supplemental material for this article is available online.
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Jacquelin Rankine, MD, MS, is an Adolescent Medicine Fellow at the UPMC Children’s Hospital of Pittsburgh.
Lauren Goldberg, MD, is a General Academic Pediatrics Fellow at the UPMC Children’s Hospital of Pittsburgh.
Elizabeth Miller, MD, PhD, is Division Director of Adolecent and Young Adult Medicine and Professor of Pediatrics, Public Health, and Clinical and Translational Science at the UPMC Children’s Hospital of Pittsburgh.
Lori Kelley, MSN, RN, CSN, is a practicing certified school nurse and member of the Pennsylvania Association of School Nurses and Practitioners.
Kristin N. Ray, MD, MS, is Associate Professor of Pediatrics at the UPMC Children’s Hospital of Pittsburgh.
1 Adolescent and Young Adult Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
2 Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
3 Pennsylvania Association of School Nurses and Practitioners, Sewickley, Pennsylvania, USA
Corresponding Author:Jacquelin Rankine, Adolescent and Young Adult Medicine, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, 120 Lytton Avenue, 2nd Floor, Pittsburgh, PA 15213, USA.Email: jacquelin.rankine@chp.edu
