How school nurses can help fight chronic absenteeism: Research

U.S. public schools wrestled with chronic absenteeism long before the COVID-19 pandemic began. Since then, however, the proportion of students considered chronically absent — meaning they have missed 10% or more of the school year — has nearly doubled, data from the U.S. Department of Education show.

Almost 31% of public school students were chronically absent during the 2021-22 academic year, the most recent year for which federal data is available. That’s up from 16.8% in 2018-19. Although many states have reported small improvements in more recent years, absentee rates generally remain higher than before the pandemic.

Public schools in the U.S. typically operate on a 180-day calendar. School administrators flag kids as chronically absent if they miss 18 or more days of school, even if those absences are excused.

Research has established that missing class can have a significant impact on children’s grades, standardized test scores and odds of graduating high school. In fact, absenteeism is one of the most common metrics schools use to measure student success, as required by the Every Student Succeeds Act, which President Barack Obama signed in late 2015.

Education leaders and researchers are not sure exactly why so many kids are missing so much school lately. Thomas Dee, an education economist at Stanford University, thinks school closures at the start of the pandemic and the switch to online-only instruction played a key role, he writes in an analysis published earlier this year in PNAS, an academic journal of the National Academy of Sciences.

Chronic absenteeism increased more in parts of the U.S. where public school students learned remotely for a larger portion of the 2020-21 academic year, he finds.

“The large and broad increases in chronic absenteeism indicate many students are failing to re-engage in schooling as in-person instruction returned,” he writes.

Efforts to fight chronic absenteeism

During the past several years, schools and local governments nationwide have launched a variety of initiatives aimed at increasing attendance. For example, the Oakland, California, school district launched a pilot program in 2023 that includes paying 45 chronically absent students $50 each week they get perfect attendance. In Abilene, Texas, elementary schools have challenged one another to friendly competitions, using their marquee signs to playfully trash talk and get their communities involved in boosting attendance.

Some efforts focus specifically on local businesses or parents. Earlier this year, Rhode Island’s secretary of commerce wrote a letter to local businesses asking them to be flexible with student employees’ work schedules so they do not interfere with school commitments. Meanwhile, officials in Martinsville, Virginia, announced Sept. 10 that they stiffened the criminal penalty for the parents and guardians of chronically absent children.

Parents and caregivers there can now be charged with a Class 1 misdemeanor, which comes with a fine of up to $2,500 and possible jail time, instead of a less serious Class 3 misdemeanor, which carries a fine of up to $500, the Cardinal News reports.

Researchers Erin Maughan and Knoo Lee, who study student absenteeism, say many schools either do not realize or underestimate the potential of one of their strongest resources in the fight against chronic absenteeism: school nurses.

“There’s a general misunderstanding about the broader role they could play, and they’re often held back by tight funding and staffing shortages,” Lee, an assistant professor at the University of Missouri’s Sinclair School of Nursing, wrote in an e-mail to The Journalist’s Resource.

Helping ensure kids come to school and don’t leave unnecessarily

A common misconception is that a school nurse’s job is primarily to take students’ temperatures, give out bandages, ice packs and Tylenol, and call parents and guardians to pick up kids who are sick or injured. But school nurses are trained to spot, prevent and help students overcome problems that can affect attendance.

For instance, school nurses can help students develop plans for managing chronic illnesses such as asthma, one of the leading causes of school absenteeism, according to the U.S. Centers for Disease Control and Prevention.

Nurses can also intervene to help parents and other caregivers handle health-related issues such as obesity and attention deficit/hyperactivity disorder. Academic studies have found both are associated with higher rates of student absenteeism.

School nurses also often provide personal hygiene items such as tampons. Teenagers have reported skipping school because they could not afford menstrual products.

Maughan, an associate professor at George Mason University’s School of Nursing, notes that nurses are generally good at getting kids to open up about barriers that keep them from going to school, including unreliable transportation, unstable housing, mental health issues, difficulty getting in to see a dentist and not having cold weather gear.

Once nurses know what a student is up against, they can work with families and school officials to find solutions, Maughan explains.

“Nurses also work with teachers to keep students in class,” she says.

The American Academy of Pediatrics emphasizes how important that is in a 2016 policy statement published in the academic journal Pediatrics.

Nurses aim to get kids back to class as quickly as they can, when that is possible. Research conducted in Kentucky suggests that when a school nurse is present to evaluate students, the vast majority who seek help for an injury or illness return to class to finish the school day.

Kids miss school for many reasons. Some of the most common are:

Illness and injury. Students might be out for a few days fighting off a cold or the flu. But serious injuries such as those sustained in a car crash can interfere with regular attendance, as can chronic diseases such as asthma, diabetes and obesity.

Poverty. Some students skip school because they lack school supplies, personal hygiene products, clothing or cold weather gear. Some work to help support their families. Unreliable transportation and unstable housing also can cause children to miss school.

Misconceptions about the importance of attendance. Some parents mistakenly assume attendance in the early grades is not as important as it is in high school. Some don’t think missing school is a big deal if a child’s absence is excused.

Disengagement. Some students skip school because they are bored or don’t get enough academic support to pass their classes. Not feeling connected to teachers, classmates and other people on campus can also discourage attendance.

Safety concerns. When students feel unsafe at school because of bullying, sexual harassment, gang activity or fear of school shootings, they often try to avoid going.

Mental health issues. Anxiety disorders, eating disorders, depression, phobias and other mental health issues can interfere with attendance. So can emotional turmoil associated with divorce, abuse, neglect, family conflict and peer conflict.

When a nurse is not around, school personnel often send students home needlessly, the American Academy of Pediatrics points out in its policy statement, which it reaffirmed last year. It also points out that school nurses’ primary duty originally was to “support educational achievement by promoting student attendance.”

“The first school nurse, Lina Rogers, was appointed in 1902 to tend to the health of 8,671 students in 4 separate schools in New York City,” according to the policy statement. “Her early success in reducing absenteeism led to the hiring of 12 more nurses.”

Maughan says students sometimes go to the school nurse complaining they don’t feel well and asking to be sent home so they can avoid something at school. Often, it’s a bully, test or class presentation. Because of this, Maughan adds, nurses also play an important role in identifying bullying, test anxiety and other issues that can cause students to dislike school or feel unsafe.

What the research says

Academic studies suggest that no single change, on its own, is likely to make a drastic difference. Considering the wide range of reasons students miss school, education leaders need a strategy that is both multi-faceted and tailored to the needs of each school, researchers assert.

Researchers have found that school nurses have helped boost student attendance for some students in some parts of the country. But the issue remains understudied and experts have conducted few randomized controlled trials — a type of scientific inquiry that allows the experiences of students who engage with school nurses to be compared against the experiences of similar students who do not.

One of the most recent academic papers on school nurses and absenteeism was published last year in PLOS ONE, a journal of the Public Library of Science. The authors analyzed 16 different reviews of academic research on the effectiveness of school nurses across various areas of their work. Taken together, the 16 research reviews, all of which were published between 2002 and 2021, capture the findings of hundreds of papers written by scholars worldwide over several decades.

Among the main takeaways: “It is clear that school nurses play a key role in improving the health of children with asthma and diabetes,” the authors write.

The authors mention three studies of student absenteeism that they deem to be most reliable. Each examines school nurses in a different state: New York, Tennessee and Florida.

Rochester, New York

One study, published in 2011, found that children with asthma who received asthma medication from nurses at school had fewer absences than children with asthma who did not.

A total of 530 children from 67 schools and preschools in Rochester, New York, participated in the study, which ran from late August to mid-November each year for three years, starting in 2006. Nurses administered preventative asthma medication to half those children during the school day. The other half did not receive asthma medication from a school nurse.

Researchers found that students who received asthma treatments at school missed an average of 0.3 days of school every two weeks. Students who did not receive the in-school treatment missed an average of 0.5 days every two weeks.

“Children receiving the intervention experienced almost 1 symptom-free day per 2 weeks more than children in the control group,” researchers write in JAMA Pediatrics, a journal of the American Medical Association. “This translates into approximately 2.5 weeks of additional symptom-free days during a school year. In addition, children in the treatment group had fewer days with activity limitation, had fewer days of school missed, and were less likely to have an exacerbation that required treatment with systemic corticosteroids.”

Memphis, Tennessee

A 2006 study looks at asthma case management in elementary schools in Memphis, Tennessee. It found that children with asthma who participated in a nurse-led asthma education program had half as many absences, on average, as children with asthma who attended schools that did not offer the program.

The 115 students who participated in the program missed an average of 4.38 days of school during the first year of the program, which ran from October through May of the 1999-2000. The 128 children with asthma who did not participate missed an average of 8.18 days.

During that time, school nurses met weekly with 115 students at eight schools to discuss managing their asthma. Nurses also tracked the students’ attendance and worked with parents, health care providers and school staff members to coordinate their medical care. A children’s medical center in Memphis provided nurses for the school district.

“These data show that school-based nurse CM [case management] in an urban school system partnered with an academic medical facility can significantly reduce school absences and hospitalizations,” researchers write in the Journal of School Health.

Palm Beach County, Florida

Another study, published in 1975 in the American Journal of Public Health, found that school nurses helped reduce chronic absenteeism at six elementary schools in Palm Beach County, Florida.

For one academic year, nurses from the local health department gave focused attention to 302 children at six schools who had each had 14 or more absences during the prior academic year. As a comparison, researchers also tracked absences among 302 students at six local elementary schools that did receive such personalized attention.

Nurses developed improvement plans for each chronically absent student who participated in the program. Although student plans varied, nurses used a variety of strategies to improve attendance, including home visits, phone calls to families and nurse-pupil conferences. Researchers found that the 302 students who received that personalized attention missed two fewer days of school, on average, than students who did not.

Recognizing school nurses’ potential

Despite scholarly evidence that they can help, school nurses often are not included on lists of best practices for improving attendance. Hedy Chang, executive director and founder of Attendance Works, a nonprofit organization that helps schools and communities reduce chronic absenteeism, offers two reasons why that might be.

Not all schools have a nurse, and part-time nurses “don’t have the time to get involved in anything other than the most pressing medical issues and not prevention and early intervention activities that contribute to better attendance,” Chang wrote to The Journalist’s Resource in an email.

“In addition, we too often operate in silos, where we treat health and school attendance as separate issues when they need to be seen as interrelated,” she wrote.

The Attendance Playbook, a report Attendance Works compiled with FutureEd, a think tank at Georgetown University, discusses the potential of school nurses.

Another report from Attendance Works, written in collaboration with the Network for Public Health Law and National Association of School Nurses, spotlights “promising practices.”

“Whether by simply providing the health services necessary for students to be present and engaged in class, or by taking a more proactive role in addressing student attendance, school nurses are a key and highly underutilized ally in ensuring that students are in school every day,” the authors of that report write.

A nationwide shortage of nurses

Making nurses a larger part of school efforts to cut chronic absenteeism could be difficult. A big reason: Lots of schools either do not have nurses or have one part-time.

Federal law does not require schools to employ nurses. Nine states do not require it either, according to the National Association of State Boards of Education. However, the CDC recommends at least one full-time nurse for every 750 students.

In 2021, 65.7% of public schools had a full-time school nurse, according to a survey of school nurses conducted by the National Association of School Nurses.

Federal records offer a more precise estimate. However, the data is older. A report the National Center for Education Statistics compiled in 2020 shows that 52% of public schools had at least one full-time nurse during the 2015-16 academic year while 32% had at least one part-time nurse.

Federal data also show that elementary schools and middle schools were more likely to have a school nurse than high schools, and that traditional public schools were more likely to have one than charter schools. At the same time, schools where a larger percentage of students qualify for free or reduced-price school meals are less likely to have a full- or part-time nurse than schools where a smaller percentage of students qualify.

Of the schools that have nurses, nurse-to-student ratios vary widely. In 2022, ratios ranged from one school nurse for every 500 students in Alabama and Vermont to one nurse per 3,000 students in Tennessee, Child Trends reports.

The nonprofit research organization also reports that many schools districts do not follow their state’s law or recommendation related to nurse-student ratios. A 2022 report from the Indiana Commission on Public Health confirms this in that state.

Another major challenge: Schools, hospitals and medical facilities are all struggling to find nurses amid a nationwide nursing shortage. Federal officials predict the shortage will continue through 2037. This month, the National Center for Health Workforce Analysis projected a shortage of 307,010 full-time registered nurses and 146,710 licensed practical nurses nationwide in 2027.

Some school nurses are leaving for other jobs. Sheila Caldwell, a school nurse in New Jersey, told NEA Today, a publication of the National Education Association, that school nurses are not compensated according to their value.

“The role isn’t even that well understood within the nursing field itself,” Caldwell told NEA Today last year. “This is not a cake job. We are managing high needs of students every day, treating kids with asthma, diabetes, epilepsy, and other health conditions.”

Focusing on partial-day absences

Lee, the assistant professor at the University of Missouri’s Sinclair School of Nursing, studies chronic absenteeism in the Midwest. Based on his findings, he recommends that U.S. schools look at partial-day absences in addition to full-day absences when developing strategies to reduce absenteeism.

Lee found that students who often miss part of a school day tend to eventually start missing a lot of full days, he wrote in an email to The Journalist’s Resource.

“We have documented causal links between partial-day absences and full-day absences, which can then lead to [chronic absenteeism],” he wrote.

He also noted that school nurses are in an ideal position to intervene.

“Because they’re typically the first point of contact for students leaving early due to illness or other issues, they’re in a unique position to spot patterns in student absences,” Lee wrote. “They can often see when partial-day absences start stacking up — an early sign that a student might be at risk for [chronic absenteeism].”

Nurses will need support to do that, though.

“By providing them with the resources and time to document and act on these patterns, we could make meaningful progress in reducing chronic absenteeism,” he added.

How school nurses can help fight chronic absenteeism