The Journal of School Nursing2025, Vol. 41(3) 370–382© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405231210959journals.sagepub.com/home/jsn
AbstractRegular attendance is integral for students’ academic success; it also affects adolescents’ physical and mental health. Very few studies consider (a) differences between partial- and full-day absences regarding chronic absenteeism (CA; missing school ≥15 days in an academic year); or (b) roles of school nurses in addressing student absenteeism. This study describes school nurses’ perceptions of factors related to CA and differences between partial- and full-day absences by analyzing qualitative data from six focus groups with 21 Midwestern school nurses. Four themes emerged: Absenteeism at the intersection of family and health; Absenteeism at the intersection of family and school; Absenteeism at the intersection of family and ecological systems; and School nurse roles in supporting chronically absent students. Findings highlight the importance of school nurses by describing their role in identifying students who are at risk for CA, allowing for effective assessment and intervention with students before patterns of CA become habitual.
Keywordschronic absenteeism, partial-day absences, qualitative research, school absences, school nurse knowledge/perceptions/self-efficacy
Students who miss 10% or more of their scheduled school days are considered to be chronically absent. In 2016, over seven million students were chronically absent in the United States, which affects both their health and academic performance (Gottfried, 2019; U.S. Department of Education, 2019). Regular school attendance is associated with the development of persistence, problem-solving, and cooperation with peers to achieve goals (Allison et al., 2019; Kassarnig et al., 2017). In contrast, chronic absenteeism (CA) detrimentally impacts students’ academic success as measured by grade failure, graduation rates, and dropout rates when compared to students attending school regularly (Amor et al., 2020; Hernandez, 2011). Moreover, long-term absenteeism is associated with risky behaviors and poor outcomes including drug abuse, suicidal thoughts, and unintended pregnancy (Hill & Mrug, 2015; Stempel et al., 2017).
Despite the negative effects of absenteeism on students’ health and wellbeing, CA is inconsistently measured and defined in the literature (Cicutto et al., 2013; Rogers & Feller, 2018; Spirito et al., 2018), which has resulted in numerous states adopting distinct guidelines for reporting absenteeism (South Carolina Department of Education, n.d.; State of New Jersey Department of Education, 2020; State of Pennsylvania Department of Education, n.d.). Further, very few studies acknowledge that partial-day absences (e.g., arriving late or leaving early) are equally as prevalent as full-day absences and that potential differences exist in risk and protective factors associated with partial-day absences as compared to full-day absences (Whitney & Liu, 2017).
There are a wide range of contributing factors associated with CA. Perhaps most notable are family-related risk factors associated with socio-demographics factors (e.g., family income, educational status, family structure and size) and family management practices (Chang & Romero, 2008; Lim et al., 2019, Singer et al., 2021). In a report from the National Center for Children in Poverty, Romero and Lee (2008) described risk factors for CA to include: “low parental education; poor parental physical and mental health; large family size; child maltreatment; non-stimulating home environment; little parental responsiveness, teaching and interaction; and parent involvement with the justice system” (p. 1). Fortunately, engaging family members in CA interventions (e.g., communicating with families about school absences, acknowledging good attendance with both students and families) is known to have a protective effect on students who are chronically absent (Sheldon & Epstein, 2004). For example, a 2018 study of a parent-school communication intervention found beneficial effects for both the school and the family, which eventually helped students by significantly reducing CA (Smythe-Leistico & Page, 2018).
The purpose of this study was to explore school nurse’s roles in regard to both full- and partial-day student absences and describe their barriers and facilitators to addressing absenteeism, in addition to their perspectives about the influences of student absenteeism. This qualitative study collected focus group data in order to investigate the subjective experiences of school nurses (Queirós et al., 2017). A deeper understanding of the relationship between school nurse roles and full-day and partial-day absenteeism is possible due to the rich, detailed data provided by qualitative methods on the barriers and facilitators for school nurses as well as their perspectives on the CA.
School nurses often work closely with students who exhibit CA and their families (Jacobsen et al., 2016; Rankine et al., 2021; Weismuller et al., 2007). Research from Maughan (2003) and Rodriguez et al. (2013) suggests the presence of school nurses in a school has a demonstrative impact on reducing school absenteeism through school nurse identification of students at risk for CA and their on-campus care of students with chronic health issues. School nurses are integral in linking families and school systems, yet their voices are vastly underrepresented in the CA literature. Further, despite the direct relationship between school nurse roles and partial-day absenteeism (i.e., school nurse roles often include sending ill students home), no known published literature has specifically explored the topic.
To address this gap, this qualitative study explored school nurse perceptions of facilitators and barriers on absenteeism—including both partial- and full-day CA—and the school nurse role in addressing absenteeism. Guiding this study, the Kids and Teens at School (KiTeS) framework (Figure 1) explains how socioecological factors from micro to macrosystems affect school absences (Melvin et al., 2019). The KiTeS framework is an extensive ecological system strategy that centers on school absenteeism. It is grounded in proximal processes and hierarchical systems detailed in Bronfenbrenner bioecological systems model, which organizes variables that impact human development into micro-, meso-, macro-, exo-, and chrono-systems, and places school absenteeism within this framework (Bronfenbrenner & Morris, 2007; Melvin et al., 2019). The KiTeS framework has its origins in western culture (United Kingdom and Australia) and it is highly applicable to the US given its focus on school absenteeism, which is a concern shared by schools and educators in many cultures. KiTeS serves as a grounding framework for this investigation of how school nurses are now positioned, as well as a framework for identifying potential barriers and facilitators for school nurses. A comprehensive strategy of delivering care to children and their families (i.e., family-centeredness in school nursing, family-oriented approach) is thought to be effective in decreasing CA, when designed appropriately by considering its barriers and facilitators (Brown et al., 2019; Knafl et al., 2017; Mäenpää et al., 2013).
This study was conducted in collaboration with a separate larger project, the Minnesota Youth Sex Trading (MYST) project (Martin et al., 2021). Data for this study were collected from a subsection of transcripts focused on CA from six online focus groups with school nurses. Participants were currently in practice or had recently practiced as school nurses in Minnesota. Data collection was completed between June and August of 2020. Study protocols and procedures were reviewed by the University of Minnesota Institutional Review Board and the study was deemed not to be human subjects’ research.
To recruit school nurses, the research team partnered with School Nurses of Minnesota (SNOM), a professional organization that represents over 600 licensed school nurses in the state. Research team members provided SNOM leadership with a series of three recruitment emails which SNOM sent to potential participants using their email listserv. Listserv members and other nurses who met eligibility criteria (i.e., must have practiced as a licensed school nurse in Minnesota in the previous two years; have experience working as a licensed school nurse in a secondary school during their careers; speak English) were invited to provide further demographic and practice details in an initial online screener (n = 60). RNs with specialized training who are licensed by the Minnesota Board of Nursing to provide health services and support to students, staff, and school communities are known as licensed school nurses in Minnesota. To ensure that students can attend class regularly and take part in their education, they promote health and well-being through assessments, first aid, medication administration, health education, and management of chronic conditions (School Nurse Organization of Minnesota, n.d.). Recruitment emails encouraged recipients to further invite individuals who met eligibility criteria, but may not have received SNOM emails, to access an online participant screening survey.
During recruitment, potential participants were divided into groups based on practice setting (i.e., geographic location or school setting) and sorted by other characteristics (e.g., number of years of experience) from the online screening survey to maximize variability. For example, one group included nurses with practice experience in rural communities with an approximately even distribution of years of experience as a school nurse (i.e., fewer than 5 years or more than 5 years). As a result, a total of six focus groups (i.e., a group of alternative learning center [ALC]-specific or similar nurses, a group of urban nurses, two groups of suburban nurses, and two groups of greater Minnesota nurses), with a combined total of 21 school nurses, were conducted. Further details about participant demographic and practice information can be found in Table 1.
Six focus groups were conducted remotely via the telecommunication platform, Zoom Inc. A pre-interview online survey was completed by participants that confirmed demographics and asked additional questions about their experiences as LSNs. This survey included three items asking about most and least frequent reasons for CA in participant experience. Table 2 shows responses to these items as context for the experiences of the participants. A semi-structured interview guide was used. The sub-set of questions analyzed for this study asked nurses to describe: (a) students who are chronically absent; (b) vulnerable groups at risk of missing school for a partial- or full day; and (c) patterns of students who miss school for a partial- or full day. Two study team members facilitated each focus group; the lead facilitator was present for all six focus groups and assisted by one of the two co-facilitators. All participants gave verbal consent, and the focus groups were recorded using Zoom’s audio-visual recording feature and auto-transcription feature. The focus groups ranged in time from 50 to 80 min, with 20–30 min dedicated to absenteeism. Participants were provided with a $50 gift card as compensation for study participation.
Transcripts generated through auto-transcription were reviewed, anonymized, and corrected as needed to ensure accuracy, with the aid of the audio-visual recordings. Following each focus group, team members met to compare and compile notes for an audit trail to improve confirmability and determine when data saturation was achieved.
After reviewing the transcribed data, the team lead developed a structural coding framework for the content analysis (Erlingsson & Brysiewicz, 2017). Structural codes were categorized into three broad groups: (1) CA in general, (2) partial-day absences, and (3) full-day absences. The structural framework and each code were reviewed and discussed to consensus with a second coder. Using NVivo 1.0 (March, 2021), transcripts were uploaded and sorted by structural codes. Together the coding team generated and applied inductively derived descriptive codes to each segment of text. Themes were developed from descriptive codes using thematic analysis as developed by Braun and Clarke (2006). All discrepancies in coding and development of themes were discussed to consensus. Results were shared with two members of the SNOM leadership where they reviewed and provided feedback to improve the methodological integrity.
Final themes provided detailed description of school nurse perspectives of influences on absenteeism and the role of the school nurse within the school setting. Four themes emerged from the data: (1) Absenteeism at the Intersection of Family and Health, (2) Absenteeism at the Intersection of Family and School, (3) Absenteeism at the Intersection of Family and Ecological Systems, and (4) School Nurse Roles in Supporting Chronically Absent Students. While the first two themes were applicable to school absences in general, the latter two themes emerged from findings that distinguished partial- and full-day absences. Findings related to structural codes (i.e., partial- vs. full-day absences) that were adequately differentiated within a theme are included in thematic descriptions.
Differences between how families and schools supported students with physical compared to mental health issues were identified as major factors related to the experience of youth missing school. Physical health (e.g., asthma or diabetes) was mentioned briefly by multiple participants as a factor that influenced absenteeism in their schools. For instance, one participant noted:
I’m thinking of … a diabetic that we had last year in the elementary [school] and [how] his dad would drop him off at 10am, or he would come and pick him up at 2pm … [resulting in] just very irregular attendance.
However, most participants noted that for physical health cases related to absenteeism, students were usually adequately supported by families, schools, and their medical teams. As such, participants did not spend significant amount of time describing these situations.
The majority of the discussion about the health of chronically absent youth focused on mental health—particularly on how undiagnosed, untreated, or uncontrolled mental health conditions were main facilitators of absenteeism. One participant posited, “I would say the majority [of CA], 90%, it’s due to mental health; school refusal [student behavior due to] known depression, known anxiety.” Similarly, participants described how specific mental health conditions (e.g., depression), psychosomatic symptoms (e.g., stomachaches) from unspecified mental health concerns, and stress related to incidences of personal or family crises led to regularly missed instructional time.
While participants expressed that students were usually sufficiently supported in their physical health needs, they extensively described that students’ mental health needs were not being adequately addressed by the family or the school system. This topic was consistently discussed as misalignments between parental understanding of how best to manage youths’ mental health concerns and the nurses’ recommendations toward evidence-based mental healthcare. This misalignment was described as challenging and often distressing to participants. One participant became emotional when she relayed, “the hard part is the student is screaming, ‘I want help, I want help’ and the family’s like ‘nope, nope, nope.’” Participant perceptions of family attitudes of avoidance when recommended to attend to their child’s needs for mental healthcare complicated intervention occurrences. Participants expressed that family members carrying out the recommendations for mental health treatment could often times address the concerns the student was facing. Another participant described, “A lot of times, parents do not want to go down that road; they would much rather hear that it is an abdominal migraine than to hear that there could be an anxiety piece to this.” This reflection elaborates on the misalignment by displaying how, in some cases, families sought diagnosis of a physical ailment—rather than acknowledge their child’s potential psychosomatic symptoms related to untreated or undiagnosed mental health concerns. Echoing similar sentiments, another participant reflected on how a parent’s own mental health may play a role in avoiding care:
One of my really chronic absentee kids last year, I would say he’s probably got some undiagnosed mental health [condition], but so do the parents, and they don’t want to go down that road with their son; they don’t want to deal with that themselves.
Additional factors influencing family decisions to forgo mental health treatment, which in turn leads to students missing more school time, were noted by participants to include specific cultural beliefs, parental stigma about mental health treatments, and limited access to mental healthcare. For instance, one participant noted,
By far and large, I think it’s the mental health component [that drives CA], and I really feel like there are a dearth of resources available [to] families and kids…. It’s huge, and there’s a huge gap in meeting the needs of these kids and the family members as well.
Families’ abilities to afford the high cost of mental healthcare were particularly concerning to some. Another participant, who recounted parent reactions to phone calls she made after a student engaged in self-harm, described, “I am calling the crisis line for your student because they harmed themselves this morning… And the parents get mad at me; they’ve yelled at me, saying, ‘Who’s going to pay for this?’”
Though not always aligned in practice, both schools and families work together to support student health. However, in cases where absenteeism is not necessarily linked to health directly—or the link is contested—families and school systems sometimes have competing interests. For instance, across focus groups, nurses described that some families seemed to prioritize parental emotional needs over school attendance, indicating a belief that school attendance was of low priority. This phenomenon is represented in the following quotes from two participants in two separate focus groups:
[The] parents really didn’t want them to go to school, so they would develop reasons why the kids couldn’t go. They had, you know, one of them said that they had heart issues and different things that you know through the years. I saw the kids go all the way through to high school, [and it] turns out mom [just] really just wanted the kids at home.
and
In rare cases, we’ve had a couple of [times] where the parents, I think, really just want them home and kind of have a codependency situation, and [the parents’] anxiety really rises when their children aren’t there with them.
Similarly, participants described other familial priorities that took precedence over school attendance. Some priorities were noted to be understandable, such as meeting family’s physical needs over spending energy ensuring children were regularly attending school. For instance, one participant commented:
Parents, I think, are doing the best they can just to keep the roof on the house and food on the table or in the fridge, and so they just don’t have a lot of, doesn’t seem like school is the priority for their parents. So if their child says, yeah, I don’t feel good, I don’t want to go, they don’t question; they just let them stay.
The quote above also indicates that sometimes parents let their child make the decision about when they wish to attend school—a factor that participants noted was not developmentally appropriate. Participants indicated that although it is appropriate to have students stay home from school when experiencing communicable illness, students expressing vague symptoms and omitting a medical assessment ignores the parents’ responsibility to send students to school. Participants described similar concerns when parents and students failed to follow school protocols related to leaving school early. One participant illustrated this point by stating:
I think a lot of the kids that we have that are chronically absent are kids whose parents, you know, don’t see the importance of making them come to school regularly. One of the things that we see is that we’ll have a parent arrive at school to pick up their kid when they haven’t been down to the health office; they haven’t communicated with anybody. They just texted their parents and said, I want to go home come, and pick me up. And we’ll talk to them and will say, you know, the health office really needs to be involved in the decision for your child to go home. They’re not supposed to contact you; we are supposed to contact you, but it’s frustrating when it just bypass[es] the whole system, and they go home.
This perspective suggests the importance of parental attitudes when it comes to partial-day absences as well as full-day absences. Participants explained that students who do not follow protocols for leaving school early are often those at greater risk for being chronically absent in the future. By skipping the school nurses’ assessment, student bypass potential intervention by the school nurse.
Notably, school nurses differentiated between families who did not prioritize school attendance and those who struggled to understand how to adequately assess and address chronic symptoms. That is, participants acknowledged that parents might prioritize school but, on a case-by-case basis, choose to remove their child from school when the child reports subjective symptoms erroneously attributed to communicable disease. Families may not recognize that these removals have become habitual. For instance, one participant shared a struggle they experienced related to this type of case:
So, you hear some just wild diagnosis, and [I feel] they’ve went around and found a doctor, that will document something and pretty much excuse them from life. And so the parents see no reason to send them to school because they’re sick. So my role has been to really help with administration to really reinforce that school is the best place for them to be. And if they need to rest during the day, I will allow them to take breaks, but the whole idea is to get them into the building,
As objective healthcare professionals with specialized knowledge and more precise documentation of absences, participants explained that school nurses can recognize when a student should leave school or when other interventions are appropriate.
Full-day Absenteeism. The focus groups revealed school nurse perceptions on how specific family experiences intersect with macrosystems to impact CA. In particular, family access to transportation and housing stability were two factors affecting potentially unnecessary full-day absences discussed by participants. As an example, when speaking about a family for whom the school bus is their only transportation to school, one participant noted, “[One of] our three- and four-year-olds that [is] often absent is [so] because they miss their only transportation to school.” This limited access to transportation doubly impacts families when their housing is unstable. Discussing families who move frequently due to housing instability and their children who are chronically absent after these moves, a participant described, “There can be big lags in transport to [school]; it can take a week to get the transportation [set up] once they move, which can be really problematic.”
Students experiencing homelessness also have other challenges in terms attending school. Focus group participants often discussed this topic using general statements without supplying specific justification. For instance, one participant shared, “We also have a lot of the homeless [students]. We have had a couple of them that lived in hotels, and for some reason, they had trouble getting to school.” Similarly, another participant stated, “I would say of the [CA] students that I have become aware [of], a lot of them might be also special ed students or homeless and highly mobile students.” This participant added that a student’s involvement in receiving special education services may also be related to their CA, though she did not expand on why this may be the case. Other participants expanded that inadequate sleep due to housing instability affects students’ ability to have regular school attendance.
Participants also discussed how parental work schedules may contribute to full-day absences, as demonstrated in the quote below from one of our participants:
So I would like to add that my students, a lot of their moms and dads go to work before they have to go to school. And so when our secretary will pull up, you know, they’ll do a list and say, hey, you know, you want to check in with this family; this kid’s been out for X number of days, and the parents are like, What do you mean, you know, and they’re completely clueless about that.
Family working environment (e.g., strict attendance or punctuality policies at caregivers’ place of employment) was also noted as a reason that an absence that should have been a partial-day became a full-day absence. For example, one participant noted:
With my middle school age [students], none of them can drive, so if maybe they’re not feeling well in the morning and they might be feeling fine an hour later, but the parent let them stay home…[or] a kid oversleeps, and again, if the parents, already in work by the time their kid is going off to school, then the kid gets kind of a free pass and has to stay home all day.
Partial-day Absenteeism. Family experiences related to the macrosystem also impacted partial-day absences. Participants described how limited family resources, such as food insecurity, could specifically result in partial-day attendance. Across focus groups, participants described students relying on school for meals, as food was not consistently available to them at home. However, participants observed attendance patterns for some students experiencing food insecurity, such as arriving to school right before and/or leaving shortly after lunch was served. This behavior, paired also with a lack of school commitment, could lead to partial-day absences, as opposed to full-day absences. One participant illustrated, “We’ve had groups of kids that come in at lunch time… [instead of going to school] they go and hang out, and then when they get hungry, they come to school, around lunch. Pretty typical pattern for some kids.”
Participants noted that some students’ socio-economic status impacts their school attendance. In these instances, students often had more chronic partial-day absences; especially if a student’s employment contributes to financially supporting their family. Some students missed school to attend their job during school hours or the timing of their work shift impeded their ability to sleep sufficiently before school. A participant noted, “And the other reason for coming late is some of them work the night shift, so [they] sleep [in].” She also mentioned that court orders requiring students to be present at school, due to various reasons, might result in partial-day attendance: “And I would say some that also come late are mandated to come, so if they don’t show up, they don’t get whatever [legal consequence lifted].”
Full-day absenteeism. School nurses revealed that identification of students who are chronically absent and making referrals to collaborative intervention make up their primary roles in addressing full-day CA. School nurses might identify patterns of absenteeism and refer students to others who may be able to intervene more directly. Some supportive interventions were within the school system and others were in the broader community:
I had the guidance counselor involved. At least, I bounced the idea off with the guidance counselor. Well, we also have a drug treatment program…that was very close to the high school. And I suggested that she utilize them for a resource.
Participants also described collaborating with other sources of intervention including social workers, administrative staff, student assistant program teams, and local law enforcement. Participants referred to this collaborative effort as a support system for the students. One participant reflected on their role in this system as a supportive adult in the students’ lives, “I think a lot of them are really comfortable talking to the counselor, but [the school nurse is] just another support person that they maybe don’t have.” However, participants also noted limitations to their ability to collaborate within their school. Limitations such as district protocol, capacity, and privacy concerns prevented school nurses from furthering their interventions with CA students. One participant described an experience with privacy concerns:
I would try to get more school staff involved; the social worker, we have one in the building, but you know, so much of that is [difficult], I need [the student’s] consent to do that. And that makes it real difficult.. So unless they are truly harming themselves, it’s kinda stuck.
Some participants described being limited in knowing how to address CA with students who were rarely available to work with or were not able or willing to work with staff:
Last year, kids were often gone. When they did come to school, they would sleep a lot, and they were just closed; [I]couldn’t really figure out how to help them. And then they just up and left one day, so that’s always sad and frustrating.
As displayed in this quote, many participants expressed frustration about the limitations they faced but did not know how to provide further support within their scope of practice.
Partial-day Absenteeism. The school nurse role for students with chronic partial-day absences focused on meeting student needs and then returning them to instructional time. The students who school nurses identified as those chronically missing school for a partial-day frequented the health office for a wide variety of reasons. For instance, many participants identified that some students seemed to be avoiding certain classes.
I kind of have a couple high school kids that really don’t like the sciences or the math or whatever subjects, so, um, it’s very easy to pick up on their patterns with our electronic charting and coming into the health office.
Participants described how their role was to meet the students’ needs and limit the amount of instructional time the students missed. This could mean providing a space for students to take a break from instructional time to better prepare them for returning to class. For instance, students who lack quality sleep at home may be allowed to nap in the Health Office to avoid punitive consequences for sleeping in class or longer absences if the student went home to rest.
Every year there seems to be two or three students, who, they’re not sleeping at night because they’re coming into the health office, and they’re wanting to lay down, and they are sound asleep like, they didn’t sleep.
Participants also explained that for some students who arrive late to school, the Health Office acts as a space where they can take time to meet their physical needs (e.g., eating breakfast) before joining instructional time without concern about potential punitive consequences related to tardiness. For instance, one participant noted,
My room turned into the non-judgmental show up when you can eat breakfast here. Let’s start our day and I will get you back in the first hour, the best I can… I just want to support and [show] non-judgement and if you can get to my office, you’re here and you’re not absent.
Through inductive analysis of data gathered from focus group interviews with school nurses, we investigated school nurses’ perceptions of barriers and facilitators related to school absences and the differences between partial- and full-day absences. Three of the four themes that emerged from the study described school nurses’ identification of factors that influence CA. Each of these three themes revealed family-related factors as a central contributor to CA (see Table 3). The fourth theme highlights the school nurse role in supporting chronically absent children; including the crucial role of identifying and monitoring students who miss school for a partial-day. Across all four themes, school nurses describe differentiation between experiences related to partial-day absences and full-day absences.
Family support is integral to the mental health of students (Weisz, 2004). Our results confirm the crucial impact of intrafamilial support and prioritization of mental health care on alleviating student CA. Results align with recent studies emphasizing the role of family (family structure, predicable home environment) in addressing youth mental health (Glynn et al., 2021; Mood et al., 2016). School nurses reaffirmed the importance of family support in pediatric mental wellbeing and the known associations between youth mental health concerns and school absences (Wood et al., 2012).
Further, findings highlight school nurses’ perceptions of parent attitudes and behaviors related to educational engagement and that subsequently impact students’ absenteeism. In particular, study findings are consistent with research linking better school attendance with family engagement centered on the child and school (Vaughn et al., 2013). Focus group participants discussed how family reluctance or failure to address a school absence with their child might be perceived by the child as tacit permission to miss school. Findings also highlighted parents being unaware of their child’s absence due to their work schedules. Ensuring that parents are aware of each school absence through family engagement in education may promote improved absenteeism outcomes. Family interventions that improve school-family communication and engender greater family engagement, such as Bergman & Chan’s (2021) parent opt-in, text-based, and automated communications, may be a low-cost and convenient method in addressing absenteeism, especially for lowbudget school districts.
Study findings also illustrate family-related factors from the KiTeS exo- and macrosystem, such as access to resources, lack of basic needs, and low socioeconomic status, are key factors associated with school absences (e.g., students working to support family; parents unaware of child’s school absences due to work environment). Various research also suggests that housing instability and socio-economic status correlate with school absenteeism (Balkis et al., 2016; Deck, 2017; Fantuzzo et al., 2013). Parents’ responses to CA may be shaped by also having to deal with very challenging situations at home such as precarious housing and homelessness or poverty. School engagement alone may not be enough to address the high barriers presented by poverty and other forms of structural inequalities that cause families to struggle. This study highlights the importance of social infrastructure and systems (e.g., transportation, free lunches, and community support).
Responses to focus group questions revealed various factors that can help school nurses identify students who miss partial-days of school (e.g., students’ employment status, legal requirements, and access to resources such as food). The findings highlight an expanded scope of responsibilities for school nurses in handling cases involving students in need. This encompasses both independent actions and effective collaboration with various stakeholders, such as social workers, administrative staff, student assistance program teams, and local law enforcement. These results underscore the multifaceted potential of nurses’ roles, operating within both the meso- and macrosystems, which further extends the reach of their influence beyond the microsystem level. It is important to note that these findings contrast past research on school nurses’ involvement in school absences focused solely on chronic health problems such as asthma and diabetes (Best et al., 2018; Lineberry & Ickes, 2015; Maughan, 2003; Yoder, 2020). Furthermore, this study highlights that students’ self-initiated visits to the health office based on immeasurable complaints or symptoms, such as vague complaints of headaches, might be key to identifying and preventing partial-day absences. For example, in addition to conducting physical assessments and directing students to the best resources for their safety and health, school nurses can also raise a red flag for adolescents who have a similar, repetitive pattern of missing school partially. Thus, a school nurse may function as pivotal point-person in addressing CA among students (Lee et al., 2021; Whitney & Liu, 2017; Wyman, 2005).
Findings from this study highlight a unique role school nurses play within schools’ dynamics, specifically related to student engagement (Lee et al., 2021). Previous studies showed that partial-day absences are more prevalent than full-day absences, partial-day absences lead to full-day absences, and both absence types affect academic outcomes (Lee et al., 2021; Whitney & Liu, 2017; Wyman, 2005). Reflections from participants in this study revealed that students who miss school partially (i.e., those who are likely to be chronically absent and have a low level of engagement) are inclined to visit the school nurse’s office on their own. While studies focusing on self-initiated health office visits are scarce, our findings suggest that school nurses may play a significant role in addressing partial-day absences which could decrease full-day absences over time. This is consistent with previous studies noting that having contact with a school nurse resulted in fewer early releases or absences compared to students who did not have contact with a school nurse (Hill & Hollis, 2012; Wyman, 2005).
All scientific research is subject to limitations. In this qualitative study, only one male nurse participated and all focus group participants were white. Although our homogenous sample of school nurses reflects school nursing practice in Minnesota, it does limit the transferability of the results. A second consideration is that the COVID-19 pandemic has drastically altered school nurses’ roles and responsibilities. Although we asked focus group participants to reflect on experiences before and during the pandemic, study results may reflect school nurse’ perceptions based primarily on experiences prior to the pandemic. Future research in this area might find that school nurses’ roles have expanded or contracted in terms of student absenteeism.
Although study findings demonstrated the importance of systemic support, which addresses factors within the outer layers of the KiTeS’ ecological systems (i.e., macrosystem, exosystem), the effect of systemic support on microsystem and mesosystem factors, such as for families in terms of how they prioritize school attendance, requires further investigation. Similar to our previous quantitative research showing a link between school absences and risk and protective factors in the micro and mesosystems (Lee et al., 2023), the current qualitative findings suggest that interventions should include components from micro and mesosystems, such as teachers and school nurses, as well as outer layers of the ecological system.
Applying the Whole School, Whole Community, Whole Child (WSCC) model also echoes the significance of school nurses in school absences. The WSCC model is an educational strategy that prioritizes children’s overall development and acknowledges that students are more than simply their academic accomplishments and are influenced by a variety of elements, including their physical, social, emotional, and mental health (Lewallen et al., 2015). This model aligns with the indicators shared by school nurses in our study that possible problems with students’ physical, social, emotional, and mental health can be found in their absences from school. Our findings support the WSCC model, which calls for collaboration between the student, their family, and other members of the school community, such as school nurses, to identify and resolve the underlying factors generating the absences. In order to address concerns with physical health, social or emotional issues, or mental health, this may necessitate supplying support and resources, in which school nurses can once again play a significant role.
It is well established that school nurses impact student attendance (Maughan, 2003; Rankine et al., 2021; Rodriguez et al., 2013). However, school nurse roles are currently not designed to address the needs of students beyond their physical health conditions (Best et al., 2018; Simoneau et al., 2020; Weismuller et al., 2007). Case management and physical health care were discussed by participants in our study as two of the many components performed in the school nurse role. This study demonstrates the importance of advocating for a more holistic comprehension of the school nurse roles and responsibilities, especially around supporting students’ mental and emotional needs. Future research should focus on advancing the understanding of partial-day absences and their link to CA to continue shifting the perceptions of school nurses’ capabilities in supporting students. To the best of the authors’ knowledge, studies on CA primarily focus on the definition of full-day absences, while there are relatively few studies focusing on the concept of partial-day absences, and partial-day absence definitions vary widely across states. As a result, further research into the issue of partial-day absences should be done in order to fully understand its role and impact in schools, particularly with the help of school nurses, given their special role in identifying and being able to assist those who are absent from school partially, which may eventually lead to missing school for a full day and eventually chronically.
School nurses are in a unique position to intervene and ultimately prevent CA, which has profound effects on students’ academic and social outcomes (Allison et al., 2019; Hill & Mrug, 2015; Stempel et al., 2017). However, school nurses need more support from school districts to implement effective prevention and intervention efforts and respond to the various experiences chronically absent students are facing, such as mental health concerns, familial circumstances, homelessness, lack of transportation, and food insecurity. School districts can work to make sure that each school has an adequate number of certified and trained school nurses as well as the required medical equipment and supplies to deliver quality care. As highlighted by the KiTeS framework, school districts can also work with other key stakeholders, such as parents, community health organizations, and healthcare providers to create a coordinated strategy for school health. Linkages between partial-day absences and school nurses’ ability to intervene are promising directions for future research to pursue. In sum, critical opportunities exist for school nurses to support students and their families in order to promote their health and school success by addressing both partial- and full-day CA.
We thank Deb Mehr and Mary Heiman (School Nurse Organization of Minnesota) for assistance in recruiting the participants for this research.
The author(s) 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 by funding from the Sophia award—the University of Minnesota—School of Nursing Foundation.
Knoo Lee https://orcid.org/0000-0002-4339-9483
Camille Brown https://orcid.org/0000-0003-2517-3859
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Knoo Lee, PhD, RN, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.
Camille Brown, PhD, RN, School of Nursing, University of Minnesota, Minneapolis, MN, USA.
Emily Singerhouse, BA, School of Nursing, University of Minnesota, Minneapolis, MN, USA; Singerhouse Research Consulting LLC, Tampa, FL, USA; Strategic Prevention Solutions, Juneau, AK, USA.
Lauren Martin, PhD, School of Nursing, University of Minnesota, Minneapolis, MN, USA.
Barbara J. McMorris, PhD, School of Nursing, University of Minnesota, Minneapolis, MN, USA.
1 Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
2 School of Nursing, University of Minnesota, Minneapolis, MN, USA
3 Singerhouse Research Consulting LLC, Tampa, FL, USA
4 Strategic Prevention Solutions, Juneau, AK, USA
Corresponding Author:Knoo Lee, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA.Email: glxcf@missouri.edu
