An Exploration of Absenteeism among Nursing Students in the context of a South African University

Class attendance is essential in the academic performance and professional development of medical students [1]. Attendance is usually considered to reflect students’ level of engagement with their course and to be critical to students’ success; despite the potential for technological alternatives, lectures and other face-to-face sessions still tend to be the primary method of teaching at the universities [2]. The issue of student absenteeism in the South African Higher Education landscape has become a complex educational, political, and social problem that is generating increased interest among edu-


INTRODUCTION
Class attendance is essential in the academic performance and professional development of medical students [1]. Attendance is usually considered to reflect students' level of engagement with their course and to be critical to students' success; despite the potential for technological alternatives, lectures and other face-to-face sessions still tend to be the primary method of teaching at the universities [2]. The issue of student absenteeism in the South African Higher Education landscape has become a complex educational, political, and social problem that is generating increased interest among edu-in the medical schools [6]. Absenteeism inhibits students from attaining appropriate information and contact with relevant materials (clinical skills, lectures, practical sessions) that are required for effective learning to occur [6]. Absenteeism is also associated with poor academic performance, unprofessional conduct and inadequate socialisation within the profession [7].
With reference to nursing, absenteeism refers to being away from scheduled classes and learning experiences irrespective of the reasons and this does not only result in poor academic performance but also poor application of skills. Baccalaureate nursing students often experience high levels of stress during training that may result in psychological or emotional impairment during their professional life, ultimately affecting the quality of patient care they provide [8]. Absenteeism from clinical areas and lectures among nursing students is a significant problem that, if not addressed, will adversely affect the quality of nursing care [9]. Student absenteeism is still a great concern in most of the provinces such as Limpopo, Gauteng,Eastern Cape,and North West [10].
Despite explicit policies in place regarding mandatory attendance of lectures and clinical practice sessions, absenteeism is an on-going problem not only in South Africa, but it is a phenomenon that is also on the rise in universities worldwide [11]. Absenteeism as a problem is becoming a concern of every member of society because of its negative consequences at both the individual and social levels [12]. The authors further state that lecturers who spend time in class reteaching lessons take instructional time away from students who attend class regularly, and this has a negative impact on the lecturers' planning periods as the time spent on re-teaching can be used for individual assistance [12].
Students' absenteeism affects the lecturer, as they experience difficulties continuing with a new topic when students lack previous knowledge. In addition, other students who are top achievers become frustrated with the process of repeating work and lecturers view this process as unproductive and time-consuming [13]. The students miss valuable information and the use of specific examples to explain certain concepts that result from peer-lecturer interaction. Therefore, absentees are bound to miss these rich educational resources and the loss may negatively impact on the students' academic performance and study length [1,14].
Attendance is a key component in the students' retention, progression, achievement, and employability. It is, therefore, paramount for universities to have effective mechanisms in place to monitor risky students' attendance so as to positively engage with them at a premature stage [15]. The extent of student absenteeism is distinct in a number of studies conducted worldwide. In Turkey, 89.6% of students missed lectures in 2012 in a single month, with 37.1% having missed more than seven lectures [16]. The author further states that lecture attendance is an issue that has been neglected amongst students of health science. Student absenteeism has a negative effect on the morale of nurse educators, which results in lecturers being irritated by it [17]. Absenteeism at the higher education level affects the learners' learning process, and this may affect and obstruct their professional growth [18].
Lecturers are increasingly concerned about students' professionalism and their ability to serve their respective profession. There is evidence supporting the positive impact of student-lecturer relationship and interactions on a range of students' outcomes ranging from cognitive skills and behavioural changes to attitudes [19,20]. Students learn by observing lecturers and preceptors, emulating their behaviour to the extent that their decisions and future goals are shaped by faculty role models [21]. Role modeling has been shown to be a positive educational method and one which is valued by nursing students [22].
It should be noted that every student has unique needs as well as characteristics. Therefore, universities make use of teaching, learning, and evaluation strategies that highly take into account such differences [16]. A central assumption in the learning process is that an individual student's presence in an educational environment is a pre-requisite for the student to gain from such an environment [23].
Student absenteeism creates a dead, tiresome, and unpleasant classroom environment that makes students who come to class uncomfortable and the lecturer irritable [12]. It furthermore disturbs the dynamic of the teaching-learning environment and adversely affects the overall well-being of classes. According to the authors, in terms of quality, absenteeism is a waste of educational resources, time, and human potential. Student absenteeism also causes rework and wastes time of lecturers [12].
University students are regarded as young adults who are capable of making informed decisions and accepting the results of such decisions. To a program such as nursing, whereby a certain culture of professionalism has to be instilled, this poses a real concern. Professional responsibility and penalties for professional errors render even more essential the adequacy and quality of professional training in the domain of health sciences [16]. Many of the students view class attendance as demanding and stressful as compared to relaxing at their residences and engaging in other activities that are more enjoyable and attractive, like going to the movies and parties [22]. For education aimed at developing members of a profession, non-attendance is disturbing and worrisome.
In South Africa, the undergraduate nursing students undergo training for four years, with scheduled theoretical lectures and experiential learning included (South African Nursing Council Regulation [SANC] R425 of 1985 as amended) [24]. As per the School of Health Care Sciences Calendar Rule, a minimum of 75% lecture attendance in the module is required for students to gain access to the summative examination [25]. The students are also orientated and made aware of these policies at the beginning of the year and each semester. Consequently, if the student did not meet the 75% class attendance, he/she will not be permitted entry into the summative examination. Similarities regarding clinical and theoretical hours for nursing programs have been noted nationally and internationally. In the United Kingdom, in order to register as qualified nurses, the students must complete the components required for each year of the course before progressing to the next level. Overall, the program requires 50% theory and 50% practice [26,27]. Given the negative impact of student absenteeism on inadequate learning and professional development, the study sought to understand the reasons for absenteeism from the perspectives of the nursing students.

Study Design
An explorative, descriptive, and qualitative approach was followed to gain in-depth learners' views regarding factors contributing to their absenteeism in scheduled learning experiences. Focus group interviews were employed to capture the students' views regarding their absenteeism from scheduled learning activities [28]. In focus group interviews, the researcher interviewed participants with common characteristics or experiences for the purpose of eliciting ideas, thoughts and perceptions about specific topics or certain issues linked to an area of interest [29]. An unstructured interview guide with open-ended questions was used, thus allowing participants an opportunity to give their answers in their own words and to express self-opinions [30]. The unstructured interview generated rich and candid data that led to a deeper understanding of the phenomenon being researched.

Setting
The participant setting was the Department of Nursing Sciences at a University in Pretoria. A private room was used where no interruptions occurred, and privacy and comfort were ensured. The private room was organised in a round setting that enabled the participants to sit in a circle so that they can have eye contact with one another [31]. The sitting arrangement enabled interactions to take place.

Participants and Recruitment
The target population consisted of all accessible secondyear undergraduate nursing students who were enrolled for the B Cur program. The participants attended their theoretical lectures at different venues and times for different subjects on campus. A purposeful sampling technique was used in this study to select the participants for the four focus groups. Numbers ranging from 1 to 4 were written on pieces of paper and were randomly selected by students. The population consisted of 40 students. However, a total of 39 students constituted the sample size of this study. One female student excused herself from participating. The students were selected as they were identified to have in-depth knowledge and experience related to absenteeism from scheduled learning experiences.

Data Collection
Focus group interviews were used to collect data with four groups, each comprising of 9-10 participants [32]. The focus group interviews were conducted in March 2012. Focus group interview was selected as the method of choice for data collection because it appears as less threatening to many research participants, and allows participants to express their experiences and consider their own thoughts and views in the context of others' views in a way that may enhance data quality and produce richer and deeper data more rapidly than individual interviews [33]. The technique was relevant for the study as it allowed participants to communicate and explain their views in ways that do not always occur in one-to-one interviews [31,34].
In this study, the researcher was the moderator. The session was started by the moderator welcoming all the participants, and this was followed by introductions to facilitate rapport. Unstructured and open-ended questions were used to gather in-depth information, and this was supported with field notes in order to capture the experiences and thoughts of the participants. The open-ended questions allowed the participants to give free and unrestrained responses and share more information that included feelings and attitudes. All data was kept safe.
The focus group interviews were conducted in a round table format in the Department. An audio tape was used to record the interviews with permission from the participants [31]. LA facilitated the focus group interviews and had no prior interactions with the participants. Four focus group interviews were conducted and lasted for 45 to 60 minutes. MBR transcribed the interviews. Ethical approval to conduct the study was granted by the Medunsa Research Ethics Committee (MREC) of the University of Limpopo. Additionally, permission to conduct the study was granted by the Head of the Department of Nursing Science. Participation was voluntary and the students were informed that they could withdraw from the study at any time without penalty or any explanation. Informed written consent was obtained from the students before the interviews. Confidentiality and anonymity were ensured by using pseudo names instead of real names.

Data Analysis
The data were transcribed verbatim from the audio tape recordings and the field notes that the researcher took during the interviews. Tesch's method of data analysis was used [35]. The researcher carefully read the transcripts and all the similar themes were identified. The researcher then compiled a list of all the themes and grouped them according to similarities [36]. Coding of qualitative data, content analysis, and development of themes was done. Variables for coding were developed for the inductive approach.
Trustworthiness was considered as a principle to ensure rigour. Prolonged engagement, persistent observation, and member verification were carried out with the participants, and a dense description of the research methodology followed has been provided [36]. Another strength of the study is that the facilitation of the focus group interviews was done by a person experienced with the method but not familiar with the domain.

RESULTS
One theme emerged from the analysis of the data reflecting the participants' views regarding their absenteeism from scheduled learning experiences and recommendations to management. The theme was supported by four sub-themes (see Table 1 below).

Theme 1: Reasons for Absenteeism from Lectures
Students indicated that their reasons for absenteeism from lectures were as follows:

Sub-theme 1: Negative Attitudes of Lecturers
The participants explained that the negative attitudes of lecturers are a demotivating factor towards their nonattendance in class. This included destructive criticism and lack of respect.

"I just do not go to class because my or our efforts are not being valued (No 8)".
"I fear to be asked a question in class (No 14)".
The participants emphasised that poor lecturer-student relationships are a contributory factor towards student absenteeism. Therefore, they would rather occupy themselves with something else than go to class.

Sub-theme 2: Lecturers Do not Provide Guidance nor Give Prompt Feedback
The participants reported that although presentations have been introduced as another teaching method, the lecturers do not add to the subject content after their own presentations. This made them wonder if they covered all that needed to be covered or not and whether or not the presented information was correct.
"The whole block will be presentations by the students with no lecturer involvement (No 32).
"During presentations, we are not listening, some of us don't know how to present, and we don't understand the content (No 17)".
The participants stated that another factor influencing student absenteeism is the fact that lecturers come to class unprepared. However, the students recommended that the lecturers should use additional teaching strategies to reinforce learning and improve students' interest.

Sub-theme 3: Lecturers Lack Commitment, Come to Classes Late
The participants expressed their dissatisfaction with the lack of commitment from the lecturers. They stated that they are not motivated to go to class. On many occasions, it is either that the lecturer is late or does not come for class at all. The participants expressed their dissatisfaction with the lack of commitment from the lecturers. They stated that either the lecturers do not come to class, classes start late, or classes end earlier than scheduled, which is a waste of time at their end.

Sub-theme 4: Students cannot Cope with the Workload
The students indicated that they cannot juggle work and studying. Many voiced out that they come back exhausted from the clinical settings and find it difficult to study afterward. Therefore, they find it easy to miss classes as they can catch up on the study content by reading on their own.

"It is not like I enjoy bunking classes, but having to wake up in the morning after working hard in the previous shift is just too much. On the other hand, you have to study for a scheduled test the next day. This a big challenge for me because now if I attend class, I won't have enough time to prepare…. (No 28)".
The participants explained that the other factor for the students' absenteeism in the class includes exhaustion because they would be coming late from the clinical area. Furthermore, the participants also stated that preparation for assessments is among the factors that contribute towards absenteeism from class.

DISCUSSION
This study aimed to investigate the reasons for students' absenteeism from scheduled learning experiences, as well as to identify which strategies can be designed to curb the problem of absenteeism. The findings revealed that absenteeism was prevalent among nursing students. The main reasons for the non-attendance of classes were negative attitudes of the lecturers, lecturers do not provide prompt feedback, lecturers do not provide guidance, lecturers lack commitment and come to classes late and that the students cannot cope with the workload. Poor lecturer-student relationships have been identified as the contributory factor towards student absenteeism [37].
Lecturers have an important role to play concerning students' absenteeism. In these cases, it is when a lecturer makes negative remarks about a student, it may result in a student staying at home and not coming to college [38]. Approximately three-quarter of all absenteeism in Sweden involves interconnected issues, such as boredom and stressful relationships with lecturers [39]. There is a relationship between a lecturer and students' absenteeism. Lecturers should treat students in a similar way and show respect [40]. On the other hand, the above-stated reasons give poor performing students an excuse that classes are boring. Absenteeism results in lower achievement and poor academic performance. It makes students stay longer in school and parents are stressed financially. If the academic standard is not maintained, increasing absenteeism will adversely affect the quality of nursing care and contribute to increased morbidity and mortality rate in the society [41].
It is of importance that the faculty eliminates the factors that have been identified as contributing to absenteeism among nursing students. The nursing students revealed that the negative attitudes of lecturers include destructive criticism, lack of respect, as well as the aspect of no prompt feedback that is given to the students regarding the presentations. Instead of constructive feedback, such as being shown where one went wrong, students are being belittled in class in the presence of other students. The lecturers do not respect the students and they do not adhere to professionalism when speaking to students.
Absenteeism is a major concern for university education worldwide [11,42]. Student nurses' absenteeism from lectures and clinical practice may lead to great concern for the society. It can also affect public safety and lead to inadequate learning, especially in the aspect of drug calculation and administration. This could result in drug overdose, poisoning, and nursing error [41]. The problem of absenteeism among nursing students is growing and this issue should be handled properly; otherwise, it will have an adverse effect on the quality of nursing care [43].
As the literature has revealed, students' absenteeism is influenced by various aspects, which include personal, health, home, as well as study and teaching-related factors [41]. All these factors have an influence on the students' absenteeism even though the level and magnitude of each reason will differ from one student to another. Studies assert that poor teaching strategies by lecturers lead to boring lectures, unfavorable learning environment, lack of subject interest, and poor relations with lecturers [15]. In the study, half of the respondents conveyed interesting content to be an element in lecture attendance [44]. Absenteeism can be linked to a lack of interest in the subject matter and poor teaching strategies [45]. In a study conducted on medical students, the results indicated that some students could be absent from class due to improper and boring teaching methods [46]. At times, students miss classes because the content is too boring [47].
Moreover, the quality and attitudes of the lecturers are some of the reasons stated by students for non-attendance of classes [15,48]. Few (33%) respondents agreed that if the lecturer asks many questions everyday, they would be absent from the learning area, while (67%) other respondents disagreed with the statement [49]. The dislike for teaching style and the ease of understanding the subject without guidance are also a contributing factor to absenteeism [11]. The integration of more innovative teaching methods and learning strategies into the lecture, such as games and role play, enhances the probability of meeting the needs of the learners [12].
It is a fact that lecturer-absenteeism could discourage students from being absent from the class. Congruent with study findings is that when a lecturer is absent from the classroom, students' learning is disrupted; and when he/ she is repeatedly absent, students' performance can be significantly impacted in a negative way [50].
The lecturers should also consider other strategies they can use to keep students interested amid address and introductions. These ought to empower the great participation of students in the classroom [51]. In this study, the lecturers were found to be the main cause of students' absenteeism. At times they do not arrive on time to classes, and sometimes they do not attend classes at all. This demotivates students from attending classes because they know that they will not be learning anything in those classes. An affirmation is the theory of planned behavior, which states that when the lecturers are late for lesson presentations, lazy for work, and absent, such factors have an impact on the students' awareness of absenteeism [52].
The students stated that the workload is too much, which makes it impossible for them to attend classes and be expected to go for experiential learning on some other days. A study conducted at the KwaZulu-Natal College of Nursing, which aimed to explore the causes and effects of student nurses' absenteeism, revealed a majority of respondents confirming that they had a lot of work to complete and that they could not cope [53]. The study results are further supported by findings that student nurses absented themselves from class when they wanted to prepare for tests and examinations [54,55]. Contrastingly, the study findings showed that students' personal factors influenced their absenteeism and the factors included physical illness, family responsibilities and inadequate finance [4]. Oversleeping, part-time work, traffic and other problems were cited as reasons for absence from lectures [56].

Limitations and Strengths of the Study
The study was conducted in 2012, however to date, the pattern of students absenting themselves from scheduled learning activities still continues. The varied teaching methods used by lecturers and bettered learning environments have not brought any positive changes. The study was limited to only one University; hence the results could not be generalised as only limited factors have been reported. More research needs to be conducted to identify and explore the factors that facilitate student absenteeism from scheduled learning experiences in other institutions to enable findings comparison. The group participants were homogenous as they were similar to one another in terms of the characteristics, views, and experiences, which facilitated the open discussion and interaction [57].

CONCLUSION
The findings of this study highlighted that the main reasons for students' absenteeism from scheduled learning experiences were lecturer-related factors. From the results of the research, issues that were identified included the lecturers' attitudes and absence in class, teaching methods used, students not understanding the content, and too much workload, which contributed to students' absenteeism. It was recommended that effective interactive teaching strategies be introduced, a positive learning environment free from ridicule be ensured, and that the lecturers should be informed about the study findings. This will enable the lecturers to make informed decisions about their practices.

HUMAN AND ANIMAL RIGHTS
Not applicable.

CONSENT FOR PUBLICATION
Informed consent was obtained from all the participants.

AVAILABILITY OF DATA AND MATERIALS
The data cannot be made available to the public due to the confidentiality agreement between the researcher and the participants.