Hate the course or hate to go: Semester differences in first year nursing attrition

Sharon AndrewREcor.gif , REemail.gif , Yenna Salamonson, Roslyn Weaver, Ana Smith, Rebecca OReilly, Christine Taylor School of Nursing, College of Health & Science, University of Western Sydney, Campbelltown Campus, Building 7, Locked Bag 1797, Penrith South DC 1797, Sydney, New South Wales, Australia Accepted 27 December 2007. Available online 5 March 2008. http://dx.doi.org/10.1016/j.nedt.2007.12.007, How to Cite or Link Using DOI Permissions & Reprints

Summary
Most of the attrition from nursing courses occurs in the first year of study. Devising university strategies to reduce attrition requires an understanding of why students leave. The aim of this study was to explore whether students who leave a nursing course in the first semester leave for the same or different reasons than students who leave in the second semester of study. Seventeen students who had left the course were interviewed by telephone: seven in the first semester and ten in the second. In the first semester, students who leave consider themselves unprepared for university, have competing roles outside university and develop a strong dislike of the nursing course. They decide quickly that the course is unsuitable and leave. Those who leave in second semester would prefer to stay but events in their life create a crisis where they can no longer cope with university studies. These students hope to return to nursing whereas students who leave in the first semester are unlikely to consider returning. Attempts to retain students in the first semester may be futile as these students may be unsuited or uncommitted whereas there is greater scope to retain those who leave in the second semester.

Keywords
Attrition;

Wastage; Nursing students

Introduction
Attrition rates in Australian undergraduate tertiary courses are far greater in the first year than in subsequent years (Strategic Analysis and Evaluation Group, 2004). In 19942002, the attrition rate for first year undergraduate students was 20% compared with approximately 11% for second year students (Strategic Analysis and Evaluation Group, 2004). Attrition from Bachelor of Nursing (BN) courses in Australia has been estimated to range from 10% to 25% (Clare et al., 2002). The attrition statistics for the UK, USA and Canada are similar to those for Australia. In the UK for example, the overall attrition in nursing courses has been reported as 24.8% with most leaving in the first year of their studies ( [Waters, 2006a] and [Waters, 2006b]). The attrition rate for Canada has been estimated to vary from 10% to 18% (Day et al., 2005) and for California, USA as 20% (California Postsecondary Education Commission, 2003). Irrespective of the actual rates of attrition and trends, Australian universities are being pressured by the Federal Government to perform in a commercial manner. Consequently every student who fails to complete a course equates to a financial loss to the university. Attrition and retention of students have been of longstanding interest to researchers but recent times have seen a resurgence of interest in developing and implementing strategies to reduce student attrition and increase retention rates in courses. The renewed interest may be partly attributed to the fact that attrition rates are used as a measure of performance of higher education institutions (Access Economics, 2005). Admission to a pre-registration BN course in Australia is on the basis of a students University Admission Index (UAI) or an equivalent measure. This index is calculated from a students academic performance in their final year high school subjects. There are alternative admission tests for students who do not have a UAI, for example, mature-aged students. Students enrolled in undergraduate studies in Australia have a grace period each semester of about 4 weeks to decide if they want to remain in a course or withdraw. On a specified (census) date at the end of this period, the students who have not withdrawn from a course are charged a monetary fee. Attrition from higher education courses is known as wastage and dropout and has been defined in different ways, but this paper defines attrition as those students who have left a nursing course in the first year and are no

longer enrolled in the course. Attrition from nursing courses is recognised as being a complex phenomenon and not attributable to a single reason but rather to multiple reasons ( [Kotecha, 2002] and [Richardson, 1996]). Exit interviews have shown that the five main reasons given for leaving a nursing course are: family, academic, financial, health, and wrong career choice (Glossop, 2002). Clinical experience/placement and the amount of science in nursing courses have also been given by nursing students as reasons for leaving a course ( [Last and Fulbrook, 2003] and [White et al., 1999]). Other literature has addressed student demographic characteristics ( [Fleming and McKee, 2005], [Glossop, 2001] and [Glossop, 2002]) and ethnicity ( [Gardner, 2005] and [McWhirter et al., 2003]). Studies of attrition in nursing courses have been criticised as being predominantly descriptive (Kotecha, 2002). Moreover, all studies have aggregated their data across both semesters and sometimes over several years of a course. This approach ignores the possibility that the reasons for leaving will vary with the time of leaving. For example, a comparison of the attrition of first and second year students from a 4-year nursing course revealed the reasons for students leaving were broadly similar with the exception of wrong choice (Mashaba and Mhlongo, 1995). This was the second most common reason cited by first year students but was not mentioned at all by those who left in the second year (Mashaba and Mhlongo, 1995). Students who leave a course early, for example before a census date, have been labelled the disappearing student and it has been suggested that they have different characteristics from those who leave later (Bers and Nyden, 2001). If so, understanding their reasons for leaving is important if tertiary institutions are to develop strategies to retain them, particularly as few nursing studies have sought to interview students after they have left a program (Gaynor et al., 2006). In this paper the term discontinuers is used to describe students who have left during the first year of their BN course. The aim of this study was to use a qualitative perspective to explore whether students who leave the BN course in the first semester leave for the same, or different reasons, than students who leave in the second semester.

Methods
Design
This qualitative study was conducted at a university in New South Wales, Australia, where pre-registration students were studying in a BN course. The university comprised four campuses, approximately 50100 km s apart, where students studied the same BN curriculum. In accordance with Australian practices, admission to the BN course was on

the basis of a students UAI or an equivalent measure. An interview is not required for students entry to the BN course at this university. High school students may seek career advice from school career counsellors, but this not compulsory. Moreover, the university has an open day where prospective students may visit the university and discuss with academics their career choices. In the first year of their BN students study eight compulsory core subjects, four each semester. Each semester these subjects included human bioscience, including introductory chemistry; nursing practice; sociology and psychology; and the theoretical and professional concepts for nursing practice. All teaching components (tutorials, science and nursing laboratory sessions) of a subject were compulsory except for lectures. Students were surveyed, by questionnaire, early in their first and second semester of a compulsory bioscience tutorial for their BN course. The questionnaire also requested consent to collect students academic results for their first year courses, but these results are not reported in this study. Students were asked to provide contact details if they were willing to participate in a telephone interview about persistence and attrition in the BN course. Forty-four percent (352) of the first year BN students completed the questionnaire and 76% (267) gave consent to be interviewed. In both semesters, we interviewed a purposive sample of students who had given their consent. This study reports the finding of the interviews, for those who had discontinued their university studies. These participants are termed discontinuers in this study.

Procedure
By the sixth week of the BN course 5% of those who completed the questionnaire had left the BN course. Seven of these discontinuers were interviewed midway during the first semester. The interviews were conducted at this time, in preference to the end of the semester, to specifically obtain the views of students who leave the BN early in a course. Moreover it was felt that the interviews should be conducted while the experiences were still recent to these ex-students. Ten discontinuers were also interviewed after the second semester. By this time, 17% of students had left the course between the sixth week of the BN course and the end of the first year. Therefore the first year attrition rate for this BN course was 22% which is in accordance with attrition rates for Australian nursing courses (Clare et al., 2002). When interviewed, the discontinuers were asked when and why they had left, if they had sought advice before leaving, what they were currently doing, if they intended to return, and what advice they would give somebody

who wanted to enrol in the BN course. The reasons for leaving and the advice they would give to others are the subjects of this paper.

Participants
In the first semester, four women and three men were interviewed. All the participants had left before the census date. To establish if traits such as language and age were contributing factors in the decision to discontinue, the participant characteristics include whether the students were from an English-speaking background (ESB) or non-English-speaking background (NESB), and whether they were classified as high school leavers or matureage entry. High school leavers are those who completed their high school year twelve studies and enrolled in university the following year, while mature-age entry participants are students aged 21 years and older at the time of their first session of study. In the second semester six of the discontinuers interviewed were female and four were male. Irrespective of when they left, all participants who were interviewed were in paid employment at the time of interview. The background of participants who left is given in Table 1. Table 1. Participant characteristics Gender Entry characteristics

Semester 1 One High school leaver; male ESB Mature-age entry; Two NESB males Three females One female High school leaver; ESB Mature-age entry; NESB

Semester 2 One High school leaver; male ESB Mature-age entry; One ESB male Two males Mature-age entry;

NESB One female Three females High school leaver; NESB Mature-age entry; ESB

Two Mature-age entry; females NESB NESB = non-English speaking country.ESB = English speaking country. Full-size table

Ethical considerations
The relevant University Human Research Ethics Committee approved the study. With the permission of the students the interviews were audio-taped. All steps required to protect students anonymity and confidentiality were undertaken. To avoid any possibility of coercion, the interviews were conducted by a research assistant or academic teaching staff who had not been involved in the teaching of the participants being interviewed.

Data analysis
The interviews were transcribed and analysed employing the method adapted from Coffey and Atkinson (Coffey and Atkinson, 1996). This method includes the generation of codes from the data, frequent re-examination of the data, development of categories, revision of the codes and categories, and it culminates in the development of themes from the data. Three themes were identified from the findings for the first semester: Being unprepared for university, Being disappointed in myself and the course and Managing family, health and finances. Two themes were identified for the second semester: Coming to terms with reality and Reaching crisis point and tipping over. Table 2 contains the sub-categories that comprise a theme. Table 2. Themes and sub-categories derived from the participant interviews Themes and sub-categories Semester 1 Being unprepared for university Content and depth of courses

Academic skills Amount of work and study Not sure about right path

Being disappointed in myself and the course Strong dislike/hate of course Lost interest Expected to fail Lack of knowledge of university processes Finding out about the course

Managing family, health and finances Health Family commitments My age HECS debt Financial status

Semester 2

Coming to terms with reality Preparedness and reasons for starting course Finances and travel Combining work and study Clinical experience Juggling multiple roles and responsibilities Low academic expectations Changing my mind

Reaching crisis point and tipping over Major family and health issues Coping and stress Reaching crisis point Full-size table

Findings
First semester
Being unprepared for university The main features of this theme included discontinuers feeling that they were unprepared for their university studies, including the type and depth of the content of the courses, the amount of work and academic skills required, and how they thought they were not on the right path.

Discontinuers felt they were unprepared for the science component, describing it as hard and feeling unprepared because of their lack of experience in science: Yeah, well at school I didnt do science and I just found it way too hard and I did PD/H/PE [Physical Development/Health/Physical Education] and I was told that, you know, that would probably would cover it enough and it didnt, I just had no idea what was going on, so yeah, I just found it really hard and it was really stressing me out. (P1) Some discontinuers had stereotypical views of nursing and the course and were unprepared for the theoretical views of the BN course because they had expected it to be more hands-on: The main reason [that I left the course] was um I, I couldnt there was more theoretical than practical upfront, so I lost interest easily I suppose. (P5) Discontinuers felt that their academic skills such as writing and in-text referencing were not up to the required standards and were not prepared for the amount of work required of students, such as assessment tasks. Discontinuers talked about recognising that they were not on the right path; being at university, or doing a nursing course were not what they wanted to do, and decided to leave the course. Nursing was not the first choice for the younger participants with one saying: Um well, to be honest, Nursing wasnt exactly what I wanted to do, it was actually my eighth preference after my, after my UAI [University Admission Index]. So, yeah, I just, you know, decided to leave it [university/course]. (P3) The mature-aged male discontinuers talked about wanting a career change and the mature-aged females talked about starting a career, but all came to the conclusion that the nursing course was not the right career or course for them. So I think that my nursing is not uh my, my career I dont think, I [do] not consider [doing the course] any more. That is the reason [I left] and that I find other career. (P6) Being disappointed in myself and the course Discontinuers were overwhelmed with their experiences of university and their lack of preparedness for university study and were disappointed in

themselves and the course. Some felt they were going to fail the course and decided to pre-empt this by leaving: I realised pretty early on that I wasnt gonna get the grades just because Im, you know, not a science person, and um, so I decided dropping out is probably, probably a better idea than sticking around and failing. (P3) The course evoked strong negative feelings for most of the participants and many expressed a hatred for the course by the time they left: Id come home upset from it [science and the course] every day and I just didnt like it and I just figured that before I had to pay my fees there was no point in me staying cause I hated it. (P1) Managing family, health and finances This theme was concerned with the personal reasons discontinuers had for leaving, such as family commitments, health, age and financial issues. The mature-aged participants talked about how the course impacted on their family and themselves: And the whole, the family was whinging. I didnt have time for my kids and that was all Im not spending time with my children, I was always studying, that was the main [reason for leaving]. (P4) Two participants described having health issues that made them reconsider remaining in the course. Two mature-aged participants made remarks about their age and how they felt perhaps they were too old to be studying. Most discontinuers talked about the financial aspects of being at university and its impact, including the impending higher education university fees if they stayed in the course.

Second semester

Coming to terms with reality The pivotal content of this theme was discontinuers experiences that made them reflect on their studies and led them to recognise that they could not continue any longer. Although second semester discontinuers had similar experiences to those in the first semester, they were more likely to describe multiple experiences of persisting longer, or trying to overcome these difficulties. Eventually, however, discontinuers described recognising the reality that they could no longer continue in the course. Discontinuers did not describe a single experience but rather multiple experiences that led them to withdraw from study. These experiences included preparedness and reasons

for starting the course, combining work and study, financial difficulties, the reality of clinical experience, expectations about poor academic results, difficulties with juggling multiple roles and responsibilities, and concerns about the future. As with the first semester students, some participants discussed their preparedness (or lack thereof) as a factor for studying at university yet had persisted with their studies because of a need to prove to themselves or others that they could be successful, but eventually they recognised that they could not continue in the course: Um I just thought at the time [before leaving the course], no I, I couldnt do it, um it was too much for me, I did, cause I was a year 10- I only went to year 10 uh and I was a mature-age student when I hadnt been in a school environment for over ten years so I thought to try and prove something to myself and well, it was just all too much. (P11) This participant also described financial and family reasons for leaving the course. Almost all participants found the financial cost of studying at university difficult. These costs included textbooks, uniforms, university fees, living expenses and travel to university or clinical placements. Older students discussed the difficulty of providing for the family, including paying their mortgage. Despite trying to manage financially, discontinuers recognised that it was not possible to continue with the course. Although some discontinuers worked in paid employment that assisted with the financial aspects of being at university, juggling study and work presented difficulties for them: Uh yeah, at the time I was going to uni four days, and doing the two days work almost double shift and I couldnt get much time to do the study, uh thats why I found [university] quite difficult. (P17) This participant also had family and concerns about poor academic performance that contributed to the decision to withdraw from the course. As in the first semester, second semester discontinuers decided to pre-empt their anticipated poor academic outcome by withdrawing from the course even though they may have been successful in the first semester. For some discontinuers, university-organised clinical placements caused them to reflect on their career choice and their suitability for the course. For example, one participant felt that it was not possible to retain a professional detached relationship with patients and therefore it would be too emotionally demanding to remain in the course. Discontinuers also discussed that juggling multiple roles related to family, study and paid employment caused them to face the reality that they could not continue in the course (Table 2). Reaching crisis point and tipping over

Although discontinuers recognised that they may not be able to continue in the course many described reaching a crisis point that tipped them from just managing to stay in the course to having to urgently withdraw. In this theme discontinuers discussed suffering stress, depression, burnout or a major physical, mental, emotional or family crisis that caused them to reach this crisis point and leave the course. For example, one participant described how a lack of finances led to stress, malnutrition and depression, and the final decision to withdraw from the course: I was also working almost thirty hours a week, travelling between work in the city and X campus, it um took about an hour and a quarter in- by public transport, so its very impractical, like I had basically a sixty or seventy hour week and I was just so totally stressed I got really depressed, malnutrition, I didnt have enough money to eat good food I had a it was like a really bad time for me actually I I yeah. But leaving was the best thing it wasnt particularly the course, but um the uni [experience]. (P13) Another participant described how financial concerns, juggling multiple roles, and the anticipation of poor academic outcomes resulted in withdrawal from the course: Yeah I think I was starting to burn, burn out and just with the [family difficulty] and that was what tipped me over and I thought well, before I go too bad, pull out and then I can always try again when everythings settled down. (P11) Like this discontinuer, most participants talked about leaving with regret and expressed an interest in returning to studies in the future.

Discussion

This was a qualitative descriptive study that used a small purposive sample of discontinuer students from both semesters of a first year BN course, and hence the findings may be specific to the university participating in this study. Consideration of rigor in the study was addressed through the criteria credibility, dependability, confirmability and transferability (Lincoln and Guba, 1985). Credibility was achieved by establishment of trust and rapport with the interviewer. Dependability and confirmability were established by verbatim interview transcripts and by having two researchers analyse the data independently and then working together to compare and discuss the coding, categories and finally themes for the study. Participant quotes are used in the text to enable readers to judge the transferability of the findings to similar settings (Lincoln and Guba, 1985). The attrition rate of the course in this study was in keeping with expectations (Clare et al., 2002) as were the various reasons students give for

withdrawing from their course ( [Bers and Nyden, 2001], [Glossop, 2002] and [Mashaba and Mhlongo, 1995]). Although students discussed academic subjects per se, none mentioned dissatisfaction with the quality of the teaching as a reason for leaving their nursing course. This is in keeping with other studies that found few students mentioned teaching as a reason for leaving the institution (Bers and Nyden, 2001). Irrespective of the type of pre-registration in which nursing course students are enrolled, science has been a subject that students have difficulty with academically ( [Akinsanya and Hayward, 1980], [Andrew, 1998], [Caon and Treagust, 1992], [Jordan and Reid, 1997], [McKee, 2002] and [Scott, 2003]). It is not surprising therefore that discontinuers mention science as a cause of anxiety. Despite science being an integral part of nursing programs for decades it appears that some students are not informed about its inclusion in the nursing curricula or students have not prepared themselves sufficiently before enrolling in their nursing programs. Moreover the comments made by some students indicate that the stereotypical view of nursing programs as hands-on persists. The sentiments expressed by discontinuers in the first semester suggest that they could not really be retained because they were not prepared for university or their nursing course. They had stereotypical views of nursing and when confronted with the reality of the nursing course, such as the science or theoretical content, they developed strong negative feelings that they expressed as a strong dislike or hatred of the course. The discontinuers in the first semester were astute and recognised very quickly that they would not succeed or were not suited to the course. In contrast to first semester discontinuers who wanted to avoid failure by leaving, second semester discontinuers see the course as a challenge, not as a threat, and wanted to prove to themselves that they could do it. Nevertheless, they also had to leave because they reached a point where pressures from outside the university become too much to juggle with university studies. Although these discontinuers may have some reservations about preparedness for the course and recognise that they may have underestimated the finances required for the course or the difficulty of juggling multiple roles, it is not a single factor, but many, that lead them to recognise that they need to reassess their continuance in the course. For many, this recognition culminates in a crisis point where students can not continue any longer with their studies. Often this crisis is reached because of a major health or family issue. These students leave reluctantly, or hate to leave, and intend to return to nursing as soon as they can, whereas the students who leave in the first semester never intend to return. In this study discontinuers were highly likely to mention non-academic reasons for leaving their course, which is supported by Wells (2003) who also suggests that non-academic reasons may be more influential in students

reasons for leaving a course than academic reasons. The financial burden of study was a non-academic reason cited by discontinuers from both semesters. While students can defer the payment of their tuition fees students still find studying at university a financial burden. This is not limited to Australian students. A Canadian study of nursing attrition found that irrespective of the type of nursing program, financial resources was the most frequently cited reason for nursing students leaving a course (Day et al., 2005). While financial difficulties were cited by all age groups in our study, a comparative study of Scottish and Australian mature-aged students found that physical and mental problems were predicated by students financial problems (Cuthbertson et al., 2004). While some students may be able to postpone the financial costs of studying at university, such as acquiring a student loan, this may not be attractive nor feasible to others. Until there are changes to government policies that make more monies available, students entering nursing courses must be fully informed about the financial costs of studying so that they can prepare, where possible, to meet these costs. Although there is some literature that focuses on differences in reasons given for leaving a nursing course at the end of the first and second year (Mashaba and Mhlongo, 1995), no studies were identified that have explored the possibility of differences in reasons between the semesters of a first year undergraduate nursing course. Our study suggests that it is not desirable to aggregate attrition findings across a course as the reasons students leave may be semester specific and valuable data may be lost by doing this. Every nursing student who leaves before completing their BN course is not just a loss to the university but also a potential loss to the nursing workforce and community. If the nursing profession and tertiary institutions want to develop strategies to retain students, it is necessary to understand the reasons that students leave in different semesters of their courses. Implementing strategies to retain students in the first semester may not be worthwhile as these students probably are not suited or committed to the course. Targeting strategies to assist students in the second semester may be more successful. The best strategy is giving students time to sort out the multiple difficulties they experience. Some of the other strategies required to keep students at university, such as financial support, are related to Government policies and therefore may be beyond the scope of tertiary institutions.

Conclusions
The practice of aggregating semester-based findings in attrition studies may be masking the semester differences in why students leave a nursing course. In our study those who left in the first semester were not prepared for studying at university, whereas the latter group of students who left were

the real wastage to the university. Strategies to retain students should concentrate on these students.

References
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