Study environment

School health and welfare services

School health and welfare services are offered to all students during compulsory education [40]. According to law, these services aim to promote general health and wellbeing, ensure a healthy learning environment, and provide early interventions when needed [41]. These services consist of a school psychologist, a school social worker and SHC, which includes a school nurse (a public health nurse by training) and a school doctor. Nationally recommended quotas are 800 students per psychologist and social worker, 600 students per school nurse, and 2100 students per school doctor [36]. These professionals meet regularly to discuss student wellbeing on a general level. In order to discuss the situation of a particular student, a tailored multi-professional team is assembled with the permission of the respective student and/or their parent/guardian [41].

SHC is part of the public primary health care system and cost-free for students. All students have regular contact with SHC as the school nurse is legally bound to examine each student annually, and the school doctor performs health checks in first, fifth, and eighth grade [42]. The Finnish Institute of Health and Welfare defines the aims of the check-ups. The aims include several screening measures (e.g. vision and scoliosis), preventive measures (e.g. immunizations) and individual health promotion (e.g. discussions regarding sufficient sleep). The school doctor complements the screening and health promotion conducted by the nurse.

In comparison to SHC, school psychologists and school social workers focus primarily on school level work. They meet individual students only when needed, for example based on a referral from the school nurse. School psychologists concentrate on learning difficulties and mental health problems, whereas school social workers support the student in social interaction issues.

Study design

Analysis process

All identified themes were derived from the recorded data. First, the data was read multiple times by three researchers (TK, SK and KM) independently. Every quotation answering one of the research questions was then isolated. Each quotation can be traced back to the original transcript with the use of the identification code referring to the group number whence the quotation came from (focus group, FG1-10). Isolation was first done individually and findings were then compared to ascertain that all relevant data had been gathered. Any discrepancies were rechecked to determine whether the problem was in the interpretation of the data or whether a relevant quotation had been overlooked.

After isolation, KM organized the quotations thematically, whereafter TK and SK verified the result. Data regarding the reasons for school absenteeism were first categorized according to existing literature and subcategories were then created. For example, the following quotation “In some cases, something has happened at home, some family crisis which explains [the absenteeism].” (social worker, FG9) was categorized to family-related reason for absenteeism, then to the “changes in the family”subcategory. Quotations regarding SHC were first organized according to the professional background: educational professionals (consisting of (vice) principals, special education/resource/subject teachers, guidance counselors, school social workers, and school psychologists), SHC professionals (including school nurses, and school doctors), and social workers. Secondly, the quotations were divided into reasons for including or excluding SHC, and finally into thematical subcategories. For example, the quotation: “I personally consider the influence of school doctors and school nurses very minor in this whole field.” (special education teacher, FG7) was first categorized based on the profession of the participant and then as a general reason inhibiting the inclusion of SHC in absenteeism reduction. Reporting was based on the COREQ checklist [46].

Reasons for absenteeism

The reasons for absenteeism are presented in Table 2. For more details and quotations, please see S1 Data.

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Table 2. Classification of the reasons for absenteeism according to the participants of this study.

https://doi.org/10.1371/journal.pone.0264259.t002

Various health-related reasons for absenteeism were recognized, the most common being a general somatic health issue. Many participants perceived medical absences difficult to intervene in and thus a risk for continued absenteeism. However, health reasons were also considered valid reasons for absenteeism and their detrimental effects could be ameliorated by support from home. The participants also mentioned several leisure-related reasons for absenteeism. The ideation of the student towards school could also promote absenteeism.

A number of issues related to the family were identified (Table 2). The situation of the parent/guardian could be the cause of absenteeism, as could life changes that the family is undergoing.

Absenteeism was thought to mirror how much the student enjoys school. The participants identified both specific, such as relationships within the school environment, and non-specific school-related reasons that could cause absenteeism.

Reasons promoting the inclusion of SHC in absenteeism reduction

Educational professionals, SHC professionals, and social workers thought that SHC should be included in absenteeism reduction when the absences are primarily health-related. Educational professionals emphasized that they have no health care training and thus valued the opinion of SHC professionals in these situations. Educational professionals thought that it might be easier for the student to talk about physical symptoms rather than about mental health problems whereas social workers pondered whether it would be easier for parents/guardians to accept help offered by a health service rather than child protection services.

“When there are anxiety symptoms, there should be an appointment with the school doctor, so the school nurse makes the appointment and the guardian is offered this option.” (principle, FG10)

“And in my opinion this sounds like a very good structure [where a student is routinely referred to SHC after 50 hours of absences], and I also think that health services are often easier for the parents to accept, too, than getting a phone call about being reported to child protective services.” (social worker, FG9)

Both educational professionals and social workers expressed that if the reason for absences was known to be a mental health issue, the school doctor should be included to assess the need of a referral to specialized medical care. They thought that the school nurse was a good partner in these situations as the nurse is present at the school more often than the school doctor. Besides, the school nurse often participates in school welfare group meetings, which the educational professionals valued as it facilitated approaching the nurse.

“And [there is] a lot of co-operation, so that if I as a school social worker have met with a student and I feel that they might be in need of adolescent psychiatry or some other referral, then once a week we have a school doctor present and an appointment can be booked through the school nurse.” (school social worker, FG10)

“I think that the teachers’ lounge functions really well; there you can see the school nurse and there is an exchange of information and worries and thoughts.” (teacher, FG1)

School doctors perceived intervening in absenteeism as part of their job and considered themselves good partners in these situations, especially since, due to the health checks they routinely perform, they have a comprehensive understanding of the situation of the student. The doctors reported that they are infrequently able to participate in the school welfare group meetings. Thus they perceived themselves less affiliated with the school and therefore possibly better able to build rapport with the family. If the school nurse was well-integrated with the school, the doctors felt more knowledgeable about the absences of a particular student. The authority associated with health care workers also promoted their role in absenteeism reduction according to both nurses and doctors.

“So if you work as a full-time school doctor, this is everyday life. Absences are a part of the everyday. They are a part of the job. I think that it’s one of the most important aspects of the job.” (school doctor, FG6)

“[Privacy and confidentiality] are felt to be very strong [in SHC], so that if the family has issues that they don’t want the school to know about, it might be easier for them to talk about these issues with the school doctor, specifically, whom they might perceive to be a bit on the outside compared to rest of the school …” (school doctor, FG6)

“Our place is towards the end of the line, so many others—or the school nurse has first looked into it and so on, so maybe you feel like the school doctor could kind of use their authority a little and tell the guardians at an earlier stage that, really, if it’s a mild headache or a little pinch in the tummy or perhaps not even a pinch … then [the guardians] should just kind of nudge the child to school and maybe the child will start to feel better.” (school doctor, FG3)

Reasons inhibiting the inclusion of SHC in absenteeism reduction

Educational professionals, SHC professionals, and social workers were all concerned about the inability of SHC to access the electronic school records and thus being unaware of any absences. There was also a shared concern for SHC resources. Specifically, both educational professionals and school nurses perceived time constraints regarding the schedule of the nurse, wishing for more time per student as well as time to participate in health education.

“I feel that it is especially problematic, even worrying, that we have this problem—apparently originating in legislature—that health care workers are unable to access a student’s [electronic student management system] record, because it could be an especially important factor in strengthening the offered support if health care workers could immediately, in real time, see things there.” (teacher, FG1)

“Right now, at least, we have a doctor that is very interested in students who are often absent or otherwise have problems, but sometimes it’s a question of resources; a school doesn’t always have a school doctor, or then there might be more focus on broad health check-ups or on those who need a referral.” (nurse, FG1)

The educational professionals brought up a number of issues related to the main focus of SHC. They were unsure whether SHC would even be interested in absenteeism, and suspected that the interest might pertain to a certain doctor instead of being essential in their job description. Some were dissatisfied with the perceived lack of co-operation of SHC, primarily because doctors rarely participated in the school welfare group meetings. Perceived differences in work cultures further hindered collaboration. School doctors were considered a slow route to help, and were often unfamiliar among school personnel as they tend to change often. The educational professionals were sceptic of any possible effects of SHC on absenteeism.

“I would say that the school doctor, maybe even the school nurse, do somehow remain pretty unknown to the majority of students. Naturally, the nurse is more familiar than the doctor, because certain students visit the nurse quite often. But maybe in a situation where one starts to examine [the student’s] absenteeism or the problems behind it, we should perhaps include an adult who has a connection with the student.” (special education teacher, FG7)

“SHC services are not just about health check-ups. Currently, school nurses do this kind of unauthorized basic work—or the kind of work that is not considered work output—when they participate in these student consultations or the meetings of the student welfare group.” (school social worker, FG2)

Social workers were likewise concerned whether absenteeism was within the focus of SHC. Furthermore, they doubted whether school doctors would participate in a meeting with them if invited.

“So, this multi-professional needs assessment I talked about before the interview: In the future, we will include the referring party more in the assessment, so for instance from school that might be the school psychologist, school social worker, or a teacher, or whoever is considered most important; I suspect that doctors will probably be difficult to get to participate, but school nurses might participate more.” (social worker, FG8)

School nurses preferred to focus on health checks and worried about becoming burdened by any absenteeism reduction efforts. The majority of them felt that parents/guardians delegated their duties, like assessing the capability of a student to attend school, to the nurses, thus increasing the workload of the nurses.

“As I listen to everyone here I get the feeling [that people are saying] that ‘let’s burden the nurse more’, all the time, more, more, and more, so that you should be a psychiatric nurse and an acute care specialist and, in a way, the whole package, and at the same time manage the entire social side, to give advice on who to contact and when it’s needed.” (nurse, FG6)

School doctors stated that they are unable to participate in school welfare group meetings since meetings are often scheduled without considering their schedule. Doctors asserted that their inclusion in absenteeism reduction should be independent of their participation in welfare group meetings. The doctors recognized some collaboration difficulties due to inadequate facilities which may force the nurse and doctor to work at a particular school on different days and to communicate either via telephone or e-mail. They agreed that doctors tend to change frequently and thus the educational professionals might be unfamiliar with the current doctor.

“It wouldn’t work for us to be invited to every meeting, but when discussing the subject during the meeting, our role should also be considered.” (school doctor, FG5)

Doctors also mentioned that a change in legislation had precluded the educational professionals from consulting the doctor as freely as they used to since currently only anonymous consultations are permitted without the permission of the respective student. Furthermore, doctors also claimed that school nurses had a distinctly different role from doctors and that one professional is unable to substitute the other.

“It’s this law that causes it. […] There is uncertainty about whether I am allowed to ask about this or that, or can I talk about it, and … Then you ask, you consult anonymously—which is completely silly, when the subject is a child’s medical absences—when I could just get on the computer and see whether there are health issues in the background.” (school doctor, FG5)

“School nurses and school doctors don’t do the same work, and they don’t have the same perspective. Our educations are really totally different. The nurse isn’t a “little doctor,” and we can’t act as surrogate nurses; we have separate jobs and different tasks, and the expertise of both is needed.” (school doctor, FG5)