Nurse Education Today (2008) 28, 865–872

Nurse

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

Sharon Andrew *, Yenna Salamonson, Roslyn Weaver, Ana Smith,Rebecca O’Reilly, 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

02do

31

KEYWORDSAttrition;Wastage;Nursing students

60-6917/$ - see front mattei:10.1016/j.nedt.2007.12.0

* Corresponding author. Tel.61.E-mail address: s.andrew@

r �c 20007

: +61 2 4

uws.edu

Summary Most of the attrition from nursing courses occurs in the first year ofstudy. Devising university strategies to reduce attrition requires an understandingof why students leave. The aim of this study was to explore whether studentswho leave a nursing course in the first semester leave for the same or different rea-sons than students who leave in the second semester of study. Seventeen studentswho had left the course were interviewed by telephone: seven in the first semesterand ten in the second. In the first semester, students who leave consider themselvesunprepared for university, have competing roles outside university and develop astrong dislike of the nursing course. They decide quickly that the course is unsuit-able and leave. Those who leave in second semester would prefer to stay but eventsin 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 firstsemester are unlikely to consider returning. Attempts to retain students in the firstsemester may be futile as these students may be unsuited or uncommitted whereasthere is greater scope to retain those who leave in the second semester.

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Introduction

Attrition rates in Australian undergraduate tertiarycourses are far greater in the first year than in sub-sequent years (Strategic Analysis and Evaluation

8 Elsevier Ltd. All rights rese

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.au (S. Andrew).

Group, 2004). In 1994–2002, the attrition rate forfirst year undergraduate students was 20%compared with approximately 11% for second yearstudents (Strategic Analysis and Evaluation Group,2004). Attrition from Bachelor of Nursing (BN)courses in Australia has been estimated to rangefrom 10% to 25% (Clare et al., 2002).

The attrition statistics for the UK, USA andCanada are similar to those for Australia. In the

rved.

866 S. Andrew et al.

UK for example, the overall attrition in nursingcourses has been reported as 24.8% with most leav-ing in the first year of their studies (Waters, 2006a,2006b). The attrition rate for Canada has been esti-mated to vary from 10% to 18% (Day et al., 2005)and for California, USA as 20% (California Postsec-ondary Education Commission, 2003).

Irrespective of the actual rates of attrition andtrends, Australian universities are being pressuredby the Federal Government to perform in a com-mercial manner. Consequently every student whofails to complete a course equates to a financialloss to the university. Attrition and retention ofstudents have been of longstanding interest toresearchers but recent times have seen a resur-gence of interest in developing and implementingstrategies to reduce student attrition and increaseretention rates in courses. The renewed interestmay be partly attributed to the fact that attritionrates are used as a measure of performance ofhigher education institutions (Access Economics,2005).

Admission to a pre-registration BN course inAustralia is on the basis of a student’s UniversityAdmission Index (UAI) or an equivalent measure.This index is calculated from a student’s academicperformance in their final year high schoolsubjects. There are alternative admission testsfor students who do not have a UAI, for example,mature-aged students. Students enrolled in under-graduate studies in Australia have a ‘grace’ periodeach semester of about 4 weeks to decide if theywant to remain in a course or withdraw. On a spec-ified (census) date at the end of this period, thestudents who have not withdrawn from a courseare charged a monetary fee.

Attrition from higher education courses is knownas ‘wastage’ and ‘dropout’ and has been defined indifferent ways, but this paper defines attrition asthose students who have left a nursing course inthe first year and are no longer enrolled in thecourse. Attrition from nursing courses is recognisedas being a complex phenomenon and not attribut-able to a single reason but rather to multiple rea-sons (Kotecha, 2002; Richardson, 1996). Exitinterviews have shown that the five main reasonsgiven for leaving a nursing course are: family, aca-demic, financial, health, and wrong career choice(Glossop, 2002). Clinical experience/placementand the amount of science in nursing courses havealso been given by nursing students as reasons forleaving a course (Last and Fulbrook, 2003; Whiteet al., 1999). Other literature has addressed stu-dent demographic characteristics (Fleming andMcKee, 2005; Glossop, 2001, 2002) and ethnicity(Gardner, 2005; McWhirter et al., 2003).

Studies of attrition in nursing courses have beencriticised as being predominantly descriptive(Kotecha, 2002). Moreover, all studies have aggre-gated their data across both semesters and some-times over several years of a course. Thisapproach ignores the possibility that the reasonsfor leaving will vary with the time of leaving. Forexample, a comparison of the attrition of firstand second year students from a 4-year nursingcourse revealed the reasons for students leavingwere broadly similar with the exception of ‘wrongchoice’ (Mashaba and Mhlongo, 1995). This wasthe second most common reason cited by first yearstudents but was not mentioned at all by those wholeft in the second year (Mashaba and Mhlongo,1995).

Students who leave a course early, for examplebefore a census date, have been labelled ‘the dis-appearing student’ and it has been suggested thatthey have different characteristics from thosewho leave later (Bers and Nyden, 2001). If so,understanding their reasons for leaving isimportant if tertiary institutions are to developstrategies to retain them, particularly as fewnursing studies have sought to interview studentsafter they have left a program (Gaynor et al.,2006). In this paper the term ‘discontinuers’ is usedto describe students who have left during the firstyear of their BN course. The aim of this studywas to use a qualitative perspective to explorewhether students who leave the BN course in thefirst semester leave for the same, or differentreasons, than students who leave in the secondsemester.

Methods

Design

This qualitative study was conducted at a univer-sity in New South Wales, Australia, where pre-reg-istration students were studying in a BN course.The university comprised four campuses, approxi-mately 50–100 km s apart, where students studiedthe same BN curriculum.

In accordance with Australian practices,admission to the BN course was on the basis of astudent’s UAI or an equivalent measure. An inter-view is not required for students’ entry to the BNcourse at this university. High school studentsmay seek career advice from school career coun-sellors, but this not compulsory. Moreover, theuniversity has an ‘open day’ where prospectivestudents may visit the university and discuss withacademics their career choices.

Hate the course or hate to go: Semester differences in first year nursing attrition 867

In the first year of their BN students study eightcompulsory core subjects, four each semester.Each semester these subjects included human bio-science, including introductory chemistry; nursingpractice; sociology and psychology; and the theo-retical and professional concepts for nursing prac-tice. All teaching components (tutorials, scienceand nursing laboratory sessions) of a subject werecompulsory except for lectures.

Students were surveyed, by questionnaire, earlyin their first and second semester of a compulsorybioscience tutorial for their BN course. The ques-tionnaire also requested consent to collect stu-dents’ academic results for their first yearcourses, but these results are not reported in thisstudy. Students were asked to provide contactdetails if they were willing to participate in atelephone interview about persistence and attritionin the BN course. Forty-four percent (352) of thefirst year BN students completed the questionnaireand 76% (267) gave consent to be interviewed. Inboth semesters, we interviewed a purposive sam-ple of students who had given their consent. Thisstudy reports the finding of the interviews, forthose who had discontinued their university stud-ies. These participants are termed discontinuersin this study.

Table 1 Participant characteristics

Gender Entry characteristics

Semester 1One male High school leaver; ESBTwo males Mature-age entry; NESBThree females High school leaver; ESBOne female Mature-age entry; NESB

Semester 2One male High school leaver; ESBOne male Mature-age entry; ESBTwo males Mature-age entry; NESBOne female High school leaver; NESBThree females Mature-age entry; ESBTwo females Mature-age entry; NESB

NESB = non-English speaking country.ESB = English speaking country.

Procedure

By the sixth week of the BN course 5% of those whocompleted the questionnaire had left the BNcourse. Seven of these discontinuers were inter-viewed midway during the first semester. Theinterviews were conducted at this time, in prefer-ence to the end of the semester, to specifically ob-tain the views of students who leave the BN early ina course. Moreover it was felt that the interviewsshould be conducted while the experiences werestill recent to these ex-students.

Ten discontinuers were also interviewed afterthe second semester. By this time, 17% of studentshad left the course between the sixth week of theBN course and the end of the first year. Thereforethe first year attrition rate for this BN course was22% which is in accordance with attrition ratesfor Australian nursing courses (Clare et al., 2002).

When interviewed, the discontinuers were askedwhen and why they had left, if they had sought ad-vice before leaving, what they were currentlydoing, if they intended to return, and what advicethey would give somebody who wanted to enrol inthe BN course. The reasons for leaving and theadvice they would give to others are the subjectsof this paper.

Participants

In the first semester, four women and three menwere interviewed. All the participants had leftbefore the census date. To establish if traits suchas language and age were contributing factors inthe decision to discontinue, the participant charac-teristics include whether the students were froman English-speaking background (ESB) or non-Eng-lish-speaking background (NESB), and whether theywere classified as high school leavers or mature-age entry. High school leavers are those whocompleted their high school year twelve studiesand enrolled in university the following year, whilemature-age entry participants are students aged 21years and older at the time of their first session ofstudy.

In the second semester six of the discontinuersinterviewed were female and four were male. Irre-spective of when they left, all participants whowere interviewed were in paid employment at thetime of interview. The background of participantswho left is given in Table 1.

Ethical considerations

The relevant University Human Research EthicsCommittee approved the study. With the permis-sion 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 inter-views were conducted by a research assistant oracademic teaching staff who had not beeninvolved in the teaching of the participants beinginterviewed.

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Data analysis

The interviews were transcribed and analysedemploying the method adapted from Coffey andAtkinson (Coffey and Atkinson, 1996). This methodincludes the generation of codes from the data,frequent re-examination of the data, developmentof categories, revision of the codes and categories,and it culminates in the development of themesfrom the data.

Three themes were identified from the findingsfor the first semester: ‘Being unprepared for uni-versity’, ‘Being disappointed in myself and thecourse’ and ‘Managing family, health and finances’.Two themes were identified for the second semes-ter: ‘Coming to terms with reality’ and ‘Reachingcrisis point and tipping over’. Table 2 containsthe sub-categories that comprise a theme.

Table 2 Themes and sub-categories derived fromthe participant interviews

Themes and sub-categories

Semester 1Being 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 2Coming 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

Findings

First semester

Being unprepared for university

The main features of this theme included discon-tinuers feeling that they were unprepared for theiruniversity studies, including the type and depth ofthe content of the courses, the amount of work andacademic skills required, and how they thoughtthey were not on the right path.

Discontinuers felt they were unprepared for thescience component, describing it as hard and feel-ing unprepared because of their lack of experiencein science:

‘Yeah, well at school I didn’t do science andI just found it way too hard and I did PD/H/PE[Physical Development/Health/Physical Educa-tion] and I was told that, you know, that wouldprobably would cover it enough and it didn’t,I just had no idea what was going on, so yeah,I just found it really hard and it was really stress-ing me out. . ..’ (P1)

Some discontinuers had stereotypical views ofnursing and the course and were unprepared forthe theoretical views of the BN course becausethey had expected it to be ‘more hands-on’:

‘The main reason [that I left the course] was umI, I couldn’t – there was more theoretical thanpractical upfront, so I lost interest easily I sup-pose.’ (P5)

Discontinuers felt that their academic skills suchas writing and in-text referencing were not upto the required standards and were not preparedfor the amount of work required of students,such as assessment tasks. Discontinuers talkedabout recognising that they were not on the rightpath; being at university, or doing a nursingcourse were not what they wanted to do, anddecided to leave the course. Nursing was notthe first choice for the younger participants withone saying:

‘Um – well, to be honest, Nursing wasn’t exactlywhat I wanted to do, it was actually my eighthpreference after my, after my UAI [UniversityAdmission Index]. So, yeah, I just, you know,decided to leave it [university/course].’ (P3)

The mature-aged male discontinuers talkedabout wanting a career change and the mature-aged females talked about starting a career,but all came to the conclusion that the nursingcourse was not the right career or course forthem.

Hate the course or hate to go: Semester differences in first year nursing attrition 869

‘So I think that my nursing is not uh my, mycareer I don’t think, I [do] not consider [doingthe course] any more. That is the reason [I left]and that I find other career.’ (P6)

Being disappointed in myself and the courseDiscontinuers were overwhelmed with their expe-riences of university and their lack of prepared-ness for university study and were disappointed inthemselves and the course. Some felt they weregoing to fail the course and decided to pre-emptthis by leaving:

‘I realised pretty early on that I wasn’t gonna getthe grades just because I’m, you know, not a sci-ence person, and um, so I decided dropping outis probably, probably a better idea than stickingaround and failing.’ (P3)

The course evoked strong negative feelings formost of the participants and many expressed ahatred for the course by the time they left:

‘I’d come home upset from it [science and thecourse] every day and I just didn’t like it and I justfigured that before I had to pay my fees there wasno point in me staying ‘cause I hated it.’ (P1)

Managing family, health and finances

This theme was concerned with the personal rea-sons discontinuers had for leaving, such as familycommitments, health, age and financial issues.

The mature-aged participants talked about howthe course impacted on their family and themselves:

‘And the whole, the family was whinging. Ididn’t have time for my kids and that wasall . . . I’m not spending time with my children, Iwas always studying, that was the main [reasonfor leaving].’ (P4)

Two participants described having health issuesthat made them reconsider remaining in the course.Two mature-aged participants made remarks abouttheir age and how they felt perhaps they were tooold to be studying. Most discontinuers talked aboutthe financial aspects of being at university and itsimpact, including the impending higher educationuniversity fees if they stayed in the course.

Second semester

Coming to terms with reality

The pivotal content of this theme was discontinu-ers’ experiences that made them reflect on theirstudies and led them to recognise that they could

not continue any longer. Although second semes-ter discontinuers had similar experiences to thosein the first semester, they were more likely todescribe multiple experiences of persistinglonger, or trying to overcome these difficulties.Eventually, however, discontinuers describedrecognising the reality that they could no longercontinue in the course. Discontinuers did notdescribe a single experience but rather multipleexperiences that led them to withdraw fromstudy. These experiences included preparednessand reasons for starting the course, combiningwork and study, financial difficulties, the realityof clinical experience, expectations about pooracademic results, difficulties with juggling multi-ple roles and responsibilities, and concerns aboutthe future. As with the first semester students,some participants discussed their preparedness(or lack thereof) as a factor for studying atuniversity yet had persisted with their studies be-cause of a need to prove to themselves or othersthat they could be successful, but eventually theyrecognised that they could not continue in thecourse:

‘Um I just thought at the time [before leavingthe course], no I, I couldn’t do it, um it wastoo 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 – hadn’t been in a schoolenvironment for over ten years so I thought totry and prove something to myself and well, itwas just all too much.’ (P11)

This participant also described financial and familyreasons for leaving the course. Almost all partici-pants found the financial cost of studying atuniversity difficult. These costs included text-books, uniforms, university fees, living expensesand travel to university or clinical placements. Old-er students discussed the difficulty of providing forthe family, including paying their mortgage. De-spite trying to manage financially, discontinuersrecognised that it was not possible to continue withthe course.

Although some discontinuers worked in paidemployment that assisted with the financial as-pects of being at university, juggling study andwork presented difficulties for them:

‘Uh yeah, at the time I was going to uni fourdays, and doing the two days work almost doubleshift and I couldn’t get much time to do thestudy, uh that’s why I found [university] quitedifficult. . ..’ (P17)

This participant also had family and concerns aboutpoor academic performance that contributed to the

870 S. Andrew et al.

decision to withdraw from the course. As in the firstsemester, second semester discontinuers decidedto pre-empt their anticipated poor academic out-come by withdrawing from the course even thoughthey may have been successful in the first semester.

For some discontinuers, university-organisedclinical placements caused them to reflect on theircareer choice and their suitability for the course.For example, one participant felt that it was notpossible to retain a professional detached relation-ship with patients and therefore it would be tooemotionally demanding to remain in the course.

Discontinuers also discussed that juggling multi-ple roles related to family, study and paid employ-ment caused them to face the reality that theycould not continue in the course (Table 2).

Reaching crisis point and tipping over

Although discontinuers recognised that they maynot be able to continue in the course many de-scribed reaching a crisis point that tipped themfrom just managing to stay in the course to havingto urgently withdraw. In this theme discontinuersdiscussed suffering stress, depression, burnout ora major physical, mental, emotional or family crisisthat caused them to reach this crisis point andleave the course. For example, one participant de-scribed how a lack of finances led to stress, malnu-trition and depression, and the final decision towithdraw from the course:

‘I was also working almost thirty hours a week,travelling betweenwork in the city and X campus,it um took about an hour and a quarter in- by pub-lic transport, so it’s very impractical, like I hadbasically a sixty or seventy hour week and I wasjust so totally stressed I got really depressed,mal-nutrition, I didn’t have enoughmoney to eat goodfood I had a – it was like a really bad time for meactually I – I yeah. But leaving was the best thing– it wasn’t particularly the course, but um the uni[experience].’ (P13)

Another participant described how financial con-cerns, juggling multiple roles, and the anticipationof poor academic outcomes resulted in withdrawalfrom the course:

‘Yeah I think I was starting to burn, burn out andjust with the [family difficulty] and that waswhat tipped me over and I thought well, beforeI go too bad, pull out and then I can always tryagain when everything’s settled down.’ (P11)

Like this discontinuer, most participants talkedabout leaving with regret and expressed an interestin returning to studies in the future.

Discussion

This was a qualitative descriptive study that used asmall purposive sample of discontinuer studentsfrom both semesters of a first year BN course,and hence the findings may be specific to the uni-versity participating in this study. Considerationof rigor in the study was addressed through the cri-teria credibility, dependability, confirmability andtransferability (Lincoln and Guba, 1985). Credibil-ity was achieved by establishment of trust and rap-port with the interviewer. Dependability andconfirmability were established by verbatim inter-view transcripts and by having two researchersanalyse the data independently and then workingtogether to compare and discuss the coding, cate-gories and finally themes for the study. Participantquotes are used in the text to enable readers tojudge the transferability of the findings to similarsettings (Lincoln and Guba, 1985).

The attrition rate of the course in this study wasin keeping with expectations (Clare et al., 2002) aswere the various reasons students give for with-drawing from their course (Bers and Nyden, 2001;Glossop, 2002; Mashaba and Mhlongo, 1995).Although students discussed academic subjectsper se, none mentioned dissatisfaction with thequality of the teaching as a reason for leaving theirnursing course. This is in keeping with other studiesthat found few students mentioned teaching as areason for leaving the institution (Bers and Nyden,2001).

Irrespective of the type of pre-registration inwhich nursing course students are enrolled, sciencehas been a subject that students have difficultywith academically (Akinsanya and Hayward, 1980;Andrew, 1998; Caon and Treagust, 1992; Jordanand Reid, 1997; McKee, 2002; Scott, 2003). It isnot surprising therefore that discontinuers mentionscience as a cause of anxiety. Despite science beingan integral part of nursing programs for decades itappears that some students are not informed aboutits inclusion in the nursing curricula or studentshave not prepared themselves sufficiently beforeenrolling in their nursing programs. Moreover thecomments made by some students indicate thatthe stereotypical view of nursing programs as‘hands-on’ persists. The sentiments expressed bydiscontinuers in the first semester suggest thatthey could not really be retained because theywere not prepared for university or their nursingcourse. They had stereotypical views of nursing andwhen confronted with the reality of the nursingcourse, such as the science or theoretical content,they developed strong negative feelings that they

Hate the course or hate to go: Semester differences in first year nursing attrition 871

expressed as a strong dislike or hatred of thecourse. The discontinuers in the first semesterwere astute and recognised very quickly that theywould not succeed or were not suited to thecourse.

In contrast to first semester discontinuers whowanted to avoid failure by leaving, second semesterdiscontinuers see the course as a challenge, not as athreat, and wanted to ‘prove’ to themselves thatthey could do it. Nevertheless, they also had toleave because they reached a point where pressuresfrom outside the university become too much tojuggle with university studies. Although these dis-continuers may have some reservations about pre-paredness for the course and recognise that theymay have underestimated the finances requiredfor the course or the difficulty of juggling multipleroles, it is not a single factor, but many, that leadthem to recognise that they need to reassess theircontinuance in the course. For many, this recogni-tion culminates in a crisis point where studentscan not continue any longer with their studies. Of-ten this crisis is reached because of a major healthor family issue. These students leave reluctantly, or‘hate to leave’, and intend to return to nursing assoon as they can, whereas the students who leavein the first semester never intend to return.

In this study discontinuers were highly likely tomention non-academic reasons for leaving theircourse, which is supported by Wells (2003) who alsosuggests that non-academic reasons may be moreinfluential in students’ reasons for leaving a coursethan academic reasons. The financial burden ofstudy was a non-academic reason cited by discon-tinuers from both semesters. While students candefer the payment of their tuition fees studentsstill find studying at university a financial burden.This is not limited to Australian students. A Cana-dian study of nursing attrition found that irrespec-tive of the type of nursing program, financialresources was the most frequently cited reasonfor nursing students leaving a course (Day et al.,2005). While financial difficulties were cited byall age groups in our study, a comparative studyof Scottish and Australian mature-aged studentsfound that physical and mental problems werepredicated by students’ financial problems (Cuthb-ertson et al., 2004). While some students may beable to postpone the financial costs of studying atuniversity, such as acquiring a student loan, thismay not be attractive nor feasible to others. Untilthere are changes to government policies thatmake more monies available, students enteringnursing courses must be fully informed about thefinancial costs of studying so that they can prepare,where possible, to meet these costs.

Although there is some literature that focuses ondifferences in reasons given for leaving a nursingcourse at the end of the first and second year(Mashaba and Mhlongo, 1995), no studies wereidentified that have explored the possibility of dif-ferences in reasons between the semesters of afirst year undergraduate nursing course. Our studysuggests that it is not desirable to aggregate attri-tion findings across a course as the reasons stu-dents leave may be semester specific andvaluable data may be lost by doing this.

Every nursing student who leaves before com-pleting their BN course is not just a loss to the uni-versity but also a potential loss to the nursingworkforce and community. If the nursing professionand tertiary institutions want to develop strategiesto retain students, it is necessary to understand thereasons that students leave in different semestersof their courses. Implementing strategies to retainstudents in the first semester may not be worth-while as these students probably are not suited orcommitted to the course.

Targeting strategies to assist students in the sec-ond semester may be more successful. The beststrategy is giving students time to sort out the mul-tiple difficulties they experience. Some of theother strategies required to keep students at uni-versity, such as financial support, are related toGovernment policies and therefore may be beyondthe scope of tertiary institutions.

Conclusions

The practice of aggregating semester-based find-ings in attrition studies may be masking the semes-ter differences in why students leave a nursingcourse. In our study those who left in the firstsemester were not prepared for studying at univer-sity, whereas the latter group of students who leftwere the real wastage to the university. Strategiesto retain students should concentrate on thesestudents.

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