Retention and withdrawal of student nurses

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production

BACKGROUND

Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya.

METHODS

This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews.

RESULTS

From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%).

CONCLUSION

To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

Issues concerning recruitment, retention and attrition of student nurses in the 1950/60s: a comparative study

AIM

To investigate student nurse recruitment and attrition in the 1950' and 1960s and undertake comparisons to modern day concerns. The study was set in one hospital in the U.K.

BACKGROUND

In the period studied nursing was unpopular as a profession and there were difficulties surrounding recruitment. Attrition rates were high.

METHOD

Documentary analysis of 641 training records dating 1955 to 1968 was undertaken. Attrition rates, reasons for non-completion and employment following successful completion were determined.

RESULTS

Most recruits were young, unmarried, females and had overseas addresses. The majority (n = 88) had prior nursing experience. Over 69% (n = 443) successfully completed their training. Attrition rates were over 30% (n = 198), the main reason being academic failure. Following completion over 40% (n = 183) undertook midwifery training (n = 183) or secured a staff nurse post (n = 153).

CONCLUSIONS

Issues relating to recruitment, retention and attrition in the 1950s and 1960s put into context present day issues. Recent attrition rates from pre-registration nurse education have fallen, nevertheless some of the issues of yesteryear remain problematic. In the present study significant numbers of entrants left due to domestic and ill-health problems resonates with many modern day studies. Also failure to complete due to academic shortcomings continues to be a concern.

Understanding student nurse attrition: learning from the literature

Student attrition in nursing causes concern, but is not a new phenomenon. Challenges in defining and understanding attrition, changes in the commissioning of nurse education and developments within the United Kingdom National Health Service (UKNHS) and the profession contribute more generally to making this a complex topic for managers and for research. In this paper we discuss findings from an integrative review of the UK literature and discuss three levels of possible contributory factors identified from the literature (micro/individual; meso/institutional; and macro/political and professional). In conclusion, we argue that a concern with attrition is legitimate and that strategies should be put in place to respond to each level of contributory factors. Factors contributing to attrition are complex and interact. We argue that some degree of attrition is inevitable if we are to maintain standards within the profession. There is, therefore, an ethical and professional imperative for attrition in some circumstances. We suggest that Tinto's model relating to social integration might inform further research.

Nursing student descriptions that suggest changes for the classroom and reveal improvements needed in study skills and self-care

This article describes a longitudinal study that took place in a college of nursing with baccalaureate students between 2002 and 2004 at a university medical center. Its purpose was to provide a climate of success for the students yet challenge them to make additional efforts to complete the program. The qualitative section of the study consisted of students answering the following open-ended questions: (1) Describe ways that faculty can help you be successful in the future and (2) What can you do for yourself to achieve the goal of finishing the program? Students identified what change could be made in the classroom, how increased study time and skills might help, and how self-care would facilitate success. Descriptions were shared with faculty and students in an effort to improve classroom delivery, provide study tips to students, and help students become aware of increased self-care. Students as future nurses, enter practice and care for patients who will need the best care and self-care instruction. Using techniques that students identified to be successful, making efforts through hard work (increased study skills), and realizing how to better care for themselves could assist RNs in providing comprehensive and best care to patients.

The mature student question

Demographic changes resulting in an increase of mature students on to pre-registration nursing programmes within our university has lead to the development of a welcoming programme for pre-registration mature nursing students. Three questionnaires were utilised in the development and evaluation of the welcoming programme. Each questionnaire had open ended questions which were thematically collated and summarised. The closed questions were computer analysed to derive simple descriptive statistics. The main components of the welcoming programme were socialisation of the individual to university life and study skills. The study found that there was a small significant difference between the needs of mature students and of standard entry students in relation to information about the nursing course, study skills and time management. The students who participated in the welcoming programme progressed a little better on the nursing course. Students' recommendations for further development of the programme included, additional study and IT skills and an introduction to subject areas on the nursing course. If we are to continue to recruit mature students on to our nursing courses we need to ensure that supports are in place to facilitate the mature student prior to and during their nursing course.

Keeping afloat: student nurses' experiences following assignment referral

The retention of nursing students is an ongoing problem, both within the United Kingdom (UK) and internationally. While there is a plethora of literature relating to student attrition, there is an absence of evidence in relation to the experiences of those students who are struggling to meet the demands of nursing programmes. Using an inductive sociological enquiry based approach, this study sought to examine the experiences of student nurses after referral on the first attempt of a summative assessment. Nursing students who had failed an assignment (n=20) were invited to participate. Data was collected using focus groups, with the emergent themes collapsed into a concise format using thematic content analysis. Four key themes were identified: desire to succeed; acceptance of personal failure; recognition of personal attributes required for success; and responsibility for personal success and failure. Students remained on the programme, despite struggling with financial and personal difficulties, because the desire to become a qualified nurse outweighed transient hardships. This paper will illustrate the benefits of understanding the students' experiences, in order to ensure the support students receive is appropriate to their needs. Understanding the support strategies as perceived by the students may prevent further wastage from nursing programmes.

Mature women's experiences of preregistration nurse education

BACKGROUND

The government of the United Kingdom is encouraging more flexible recruitment strategies to overcome the shortage of qualified nurses. Mature women returning to education, often after completing their families, are a major target, but there has been little evaluation of their experiences as higher education students of nursing.

AIM

The aim of the study was to follow-up a previous quantitative study of mature women students' outcomes on preregistration diploma courses in order to gain a deeper understanding of their experiences, and consider ways in which their needs might be addressed.

METHODS

Five focus groups were conducted in one higher education institution, and data were analysed using thematic analysis, assisted by the 'spike' feature of Word for Windows.

FINDINGS

Three major themes were identified: 'Didn't know what to expect', 'Reality shock' and 'Learning the game'. Subthemes of 'Learning the game' were 'Academic study', 'Practice placements and shift work', 'Managing the effect of course workload on domestic roles', 'Personal growth and changing relationships', and 'Support systems and friendships'.

CONCLUSIONS

The findings are discussed in relation to reports of women's experiences in higher education in general. We conclude that the situation and needs of mature women preregistration nursing students are such that fundamental curriculum redesign is needed so that they can participate in higher education in ways that allow integration of their family and student lives, and permit them to benefit from the higher education experience in the same ways as younger students. The study is limited by its local nature, but the findings mirror those of other work, giving reassurance of its wider applicability. Recommendations are made for changes in the philosophy and organization of future programmes to improve their appropriateness and acceptability to mature women nursing students.

Why do student nurses leave? Suggestions from a Delphi study

The high dropout rate of nursing students is a major concern. However, there is little research available about the reasons why students leave. Universities collect some information from 'exit' interviews but, due to ethical sensitivities, it is not made available for research analysis. The purpose of this study was to establish a consensus view of the reasons why student nurses leave their pre-registration education programme. The study was undertaken in two phases. Initially, an exploratory phase using focus groups and one-to-one interviews was used to gather multi-professional views about the reasons why students leave. In the second phase a questionnaire was developed from the themes arising from the data analysis in phase one. The questionnaire was administered to an expert panel of student nurses in the form of a three-round Delphi Study. The consensus level was set at 75%. It is important to clarify that, for reasons stated above, the views expressed in this paper are those of current students about others who had left the programme. From this study, it is apparent that, with the exception of academic failure, there was no single contributing factor that was thought to make students leave. However, there were a number of important issues identified as factors that may result in student nurses leaving. These include communication and operational factors between the university and clinical areas, feelings of not being valued, unmet expectations, and stress. These issues were of concern to students and appeared to have a cumulative effect that led them to question whether they should continue their education programme. On the basis of these findings, several recommendations are made to improve the student nurse experience.

Exploring nurse learner wastage/persistence using a discursive approach: towards a theoretical understanding of the subject

RATIONALE AND AIMS OF THE STUDY

This article summarizes the findings of an exploratory study of nurse learner wastage/persistence conducted in England between 1996 and 2000. Given the lack of theorizing in much of the literature on nurse learner wastage/persistence, this study sought to generate a theoretical standpoint from which to explore voluntary nurse learner wastage.

DESIGN/METHODS

The theoretical standpoint developed drew together the theme of integration, derived from the work of Tinto, with the themes of identity and discourses, as conceptualized by Foucault. Accordingly, integration was defined in terms of how well the learner was able to subscribe to the subjectivities made available by the institutional discourses. One of the chief strengths of this approach was that it facilitated an understanding of the interaction between the individual and the institution in relation to wastage/persistence. A multiple case study strategy was used which focused on learners in the first year of a Project 2000 course. The case study strategy utilized a range of qualitative research methods.

FINDINGS AND CONCLUSION

The findings indicated that the institution was constituted by two major discourses: the 'apprentice' discourse and the 'autonomous' discourse. It was found that the stayers were much more integrated into the institution, hence they were able to persist on the course, by virtue of being able to manage the contradictions in their identity as a nurse and a learner that these two discourses engendered.

Student nurse attrition from pre-registration courses: investigating methodological issues

There has been increasing recent interest in student nurse attrition. Despite a long history of research into the problem, attrition rates remain a cause for concern. This paper presents a review of the research undertaken in the UK, together with an international comparison. The foci of previous studies have been diverse and have included investigation of students' leaving reasons, their experience of stress, and course-related difficulties of students in progress. This review illustrates the complexity of issues surrounding student nurse discontinuation, highlighting a number of methodological limitations of prior research. These include the lack of a common definition of attrition, low response rates in surveys, and the imprecise definition of categories of leaving reasons. There is also a dearth of studies based on the perspectives of students. In the UK there is little documentation of whether measures have been adopted to reduce attrition and there is no evidence of evaluation. If future research is to be aimed at reducing attrition, these conceptual and methodological issues need to be addressed.

Pre-registration diploma students: a quantitative study of entry characteristics and course outcomes

Nurse education has been transformed over the last decade and continuing change is likely. Nurse educators are responsible for meeting the quality assurance standards of local stakeholders and student retention and progress are important aspects of this process. As part of a monitoring exercise, an enquiry was set up to review pre-registration selection and recruitment strategies and to establish if there were any significant relationships between the characteristics of pre-registration diploma entrants and their academic achievement or completion rates. A multi-factorial tree-based technique was used for this purpose. This is one of the first British studies to consider both academic performance and completion rates for pre-registration diploma students. Four cohorts (N = 355) were studied. There was marked heterogeneity in student characteristics with a wide age distribution, a significant proportion of mature entrants with previous care experience, and considerable diversity in terms of education. Education and age were significant predictors of academic achievement: entrants with a minimum of two A levels and mature women with recent study experience did particularly well. Younger recruits with modest educational qualifications on entry performed less well in their assessments of theoretical knowledge. Younger students tended to leave more regularly, and well-qualified entrants showed a greater tendency to complete, although these relationships were not statistically significant. Multi-factorial analysis demonstrated that organisational and course characteristics have a conjoint influence on course outcomes. Although the study is concerned with Project 2000 in the United Kingdom, there are lessons to be drawn concerning the selection and support of non-traditional recruits into nursing.

Selection and retention of nurses

The selection and retention of suitable nurses has occupied the thoughts of many people who have a vested interest in maintaining standards and avoiding loss of resources. By drawing conclusions from inadequate findings inappropriate recommendations may be made. In a study that considers the psychological profiles of nurses, it would appear that it is self-esteem and a 'need to be needed' that is a crucial facet of nurses ability to cope with the job of nursing; a job that encourages the characteristics of individualism, in a working environment involving caring, that epitomises the values of connectedness. This paradox leads to nurses' inability to cope and subsequently leave the profession using one of the many acceptable labels that are widely documented. Acceptance of the underlying causes for this attrition would necessitate better support services for vulnerable nurses allowing them to recognize their own needs, and gain a personal understanding of how their vulnerability might echo that of people in their care.

Project 2000 student wastage: a case study

High wastage rates associated with the nursing profession were a contributory factor driving recent reforms in the form of Project 2000 (P2000). Such changes beg the question: to what extent has this new educational initiative affected current wastage patterns among nursing students? This paper examines whether or not this new initiative is having an effect on student wastage at a first-wave college of nursing, midwifery and health visiting which implemented P2000 in 1989. Thus far, 10 cohorts of students have been admitted on to the course, seven full-time and three part-time. It is hoped other institutions involved in nurse education and training may gain some beneficial insights from the lessons learnt and measures taken to stem wastage at the college described in this case study.

Backing out: nurse wastage associated with back pain

Results from a survey of 1008 National Health Service nurses and nursing auxiliaries leaving their current position are reported. These indicate that 1.3% of nurse leavers are leaving their positions for good solely because of back pain. Further, one nurse leaver in 29 is leaving their position with back pain as a main or contributory cause and 12% of all nurse leavers intending to leave for good cited back pain as either a main or contributory factor. The findings from this survey have implications for Health Authorities in relation to costs and manpower planning, and emphasize the need to provide further education and prompt referral and treatment to prevent long-term back morbidity and wastage, not only for registered nurses but also for nursing auxiliaries and aides.