Review: factors influencing nursing students' academic and clinical performance and attrition: an...

This article appeared in a journal published by Elsevier. The attachedcopy is furnished to the author for internal non-commercial researchand education use, including for instruction at the authors institution

and sharing with colleagues.

Other uses, including reproduction and distribution, or selling orlicensing copies, or posting to personal, institutional or third party

websites are prohibited.

In most cases authors are permitted to post their version of thearticle (e.g. in Word or Tex form) to their personal website orinstitutional repository. Authors requiring further information

regarding Elsevier’s archiving and manuscript policies areencouraged to visit:

http://www.elsevier.com/copyright

http://www.elsevier.com/copyright

Author's personal copy

Review

Factors influencing nursing students' academic and clinical performance andattrition: An integrative literature review

Victoria Pitt a,⁎, David Powis b, Tracy Levett-Jones a, Sharyn Hunter a

a School of Nursing and Midwifery, University of Newcastle, Australiab School of Psychology, University of Newcastle, Australia

s u m m a r ya r t i c l e i n f o

Article history:Accepted 13 April 2012

Keywords:Nursing studentsAcademic performanceClinical performanceAttrition

Predicted workforce shortages have resulted in government initiatives to increase student numbers in pre-registration nursing education. In tandem schools of nursing need to ensure students' progress and complete.The aim of this review was to identify factors that influence preregistration nursing students' academicperformance, clinical performance and attrition. An integrative review of both quantitative and qualitativeliterature was conducted using validated appraisal checklists. The review included studies published from1999 to 2011 in the databases: MEDLINE, CINAHL, Proquest nursing, Proquest Education (via Proquest5000), ERIC, Journals@Ovid, PsychINFO and ScienceDirect. Studies were categorised according to their impacton academic progression, clinical progression and attrition. Forty four studieswere found;most used quantitativemethodologies. The review identified that few studies explored factors that impact on students' clinical perfor-mance. The four categories that potentially impact on nursing students' academic performance and attritionwere: demographic, academic, cognitive and personality/behavioural factors. The challenge for universitiescommitted to students' success is to develop strategies aimed at addressing these factors that are appropriateto specific contexts and student cohorts.

© 2012 Elsevier Ltd. All rights reserved.

Introduction

Nursing is experiencing an international workforce shortage drivenin part by an aging population and escalating demands for health care.The United States of America's (US) labour analysts project that agingpopulations will drive a 22% increase in the nursing workforce overthe next 8 years (Lacey and Wright, 2009, p. 1). British and Australianlabour reports predict similar increases (Buchan and Seccombe, 2008;National Health Workforce Taskforce, 2009). A strategy initiated inter-nationally to combat nursing workforce shortages has been to increasethe number of students enrolled in preregistration nursing programs(American Association of Colleges of Nursing, 2009; National HealthWorkforce Taskforce, 2009; Royal College of Nursing United Kingdom,2005). However, the effectiveness of this strategy depends upon eachuniversity's ability to facilitate and support students' progress to gradu-ation. In order for students to graduate theymust successfully completeboth the academic and clinical components of the nursingprogram. Thispaper explores the factors that have been identified as influencing nurs-ing students' academic performance, clinical performance and attrition.

For the purpose of this review academic performance refers to thetheoretical components of a preregistration nursing program. This is

measured in several ways including; performance in individualcourses (Salamonson et al., 2009); grouped courses (Salamonson andAndrew, 2006; van Rooyen et al., 2006); yearly grade point average(GPA) (Donaldson et al., 2010); program GPA (McCarey et al., 2007)and the National Council Licensure Examination-Registered Nurse(NCLEX-RN), a computer based, exam conducted in the US.

Clinical performance is determined by the assessment of competence,defined by a student's ability to demonstrate the performance of profes-sional skills or behaviours (Tilley, 2008). Current research has investigat-ed students' perceptions of their clinical performance (Chapman andOrb, 2000; Chesser-Smyth, 2005), methods of competence assessment(Cowan et al., 2005; Norman et al., 2002) and factors which students'perceive impact on their learning during clinical placement, such aspart-time employment (Rochford et al., 2009), gender (Stott, 2007) andsupervision (Lofmark and Wikblad, 2001). However, few studies mea-sure how these factors impact on students' clinical assessment outcomes.Therefore, it is difficult to quantify the extent towhich clinical placementexperiences impact on the development of student's clinical competence.

Attrition is measured by the number of students enrolled in 1 yearwho do not complete or reenrol in the following year (Department ofEducation Employment and Workplace Relations, 2009). A degree ofattrition is inevitable and impacts on universities efficiency andresource allocation (McMillan, 2005). Previous studies have exploredreasons for and predictors of attrition, yet thus far most researchfocuses on students remaining in a program rather than those whohave withdrawn (Cameron et al., 2011; Last and Fulbrook, 2003).

Nurse Education Today 32 (2012) 903–913

⁎ Corresponding author. Tel.: +61 2 4921 6645; fax: +61 2 4921 6301.E-mail address: [email protected] (V. Pitt).

0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.doi:10.1016/j.nedt.2012.04.011

Contents lists available at SciVerse ScienceDirect

Nurse Education Today

j ourna l homepage: www.e lsev ie r .com/nedt


The identification of factors which impact on students' progression,performance and completion is instrumental in the planning and devel-opment of preregistration programs to ensure best outcomes for boththe institution and the student. Projected workforce shortages ensurethat this research is timely and relevant to universities, the nursingprofession and workforce planners, both nationally and internationally.

The Review

Aim

The aim of this integrative literature review was to identify factorsthat influence academic performance, clinical performance and attritionin preregistration nursing education.

Method

An integrative review was conducted based on Whittemore andKnafl's (2005) framework. This framework was considered for this re-view as it facilitates the inclusion of a large number of variables andconsiders both qualitative and quantitative evidence, with the intentto provide a broad perspective of the phenomenon. This ensured the in-corporation of primary sources such as PhDdissertations and universityreports.

To ensure a contemporary view of nursing education the reviewincluded studies published from 1999 to 2011 using MEDLINE, CIN-AHL, Proquest nursing, Proquest Education (via Proquest 5000),ERIC, Journals@Ovid, PsychINFO and ScienceDirect. Four broad searchcategories were used: nursing student, academic performance, clinicalperformance and attrition. The Boolean operator ‘OR’ and ‘AND’ wereapplied separately and in combination with the keywords to expandthese categories (see Table 1). Subsequent to the database search,hand searching of the reference lists from selected citations wasperformed. Inclusion criteria were: data collected from 1999 onward,undergraduate preregistration nursing students, university or collegeprogram, qualitative and quantitative research papers and Englishlanguage. Excluded studies were upper division programs (requiringprevious nursing tertiary education), enrolled/licensed practice nurs-ing programs, descriptive papers, discussion papers and editorials,inaccessible unpublished dissertations or dissertations and studieswhere date of sample collection was not provided.

Results

The search resulted in 2462 potentially relevant papers; of these34 were doctoral dissertations. Initially 2279 were excluded basedon the inclusion/exclusion criteria and repetition. Many doctoraldissertations were excluded primarily because of inaccessibility; thelarge amount of potentially rich evidencewhich is publically unavailablewas recognised as a limitation. The remaining 183 papers underwentdetailed examination. In instances of duplication the original dissertationor full report was retained. Of these 44met all the inclusion criteria, twowere qualitative (Rudel, 2006; Sanner and Wilson, 2008), one mixed

method (Bowden, 2008) and 41 were quantitative. Quantitative papersincluded publications, publically available dissertations and reports.

Quality of Included Studies

The large number of papers warranted the use of an appraisalmethod for both qualitative and quantitative research. All quantitativestudieswere assessed using Bowling's (2009) checklist, which provideda comprehensive checklist of 20 evaluation criteria rather than a scoringsystem to assess the quality of studies (see Table 2 and Appendix 1). Allthe 41 quantitative studies had limitations, for example generalisabilityof findings in studies was limited by the focus on individual pre-registration programs and cohorts. Nonetheless as the studies met 11to 17 items on the checklist it was felt that their quality was suitableto be included in the review. The qualitative studies were examinedusing theQualitative Assessment and Review Instrument (QARI) criticalappraisal instrument (Pearson, 2004) (see Table 2 and Appendix 2).Bowden's (2008) mixed method paper was also appraised with theQARI, as the focus of the paper was on the qualitative data. The QARIutilised 10 dichotomous criteria. One study (Bowden, 2008) was ofmedium quality (met 6 of the criteria) and two (Rudel, 2006; Sannerand Wilson, 2008) were of high quality (met 8 of the criteria).

Analysis of the 44 papers commenced with the exploration ofcountry of origin, level of program, method of analysis, independentvariables and if the dependent or outcome variables related to aca-demic performance, clinical performance or attrition. At this point itwas noted that the studies were predominately conducted in theUS, mostly explored baccalaureate level programs and applied

Table 1Search terms.

Nursing student Academicperformance

Clinicalperformance

Attrition

Students, nursing/education,nursing/education, nursing,associate/education, nursingbaccalaureate/education,nursing, diplomaprograms/undergraduatenursing student/studentcharacteristics

AcademicachievementAcademicfailureProgression

ClinicalexperienceClinicalteachingClinicalcompetence

WithdrawalStudent dropoutAcademicpersistence

Table 2Critical appraisal of literature.

Criteria Yes No

Quantitative studies critical appraisal checklist (Bowling, 2009)1 Aims and objectives clearly stated 40 12 Hypothesis/research questions clearly specified 21 203 Dependent and independent variables clearly stated 39 24 Variables adequately operationalized 36 55 Design adequately described 28 136 Method appropriate 41 07 Instruments used tested for reliability and validity 24 178 Source of sample, inclusion/exclusion, response rates described 35 69 Statistical errors discussed 5 3610 Ethical considerations 25 1611 Was the study piloted 4 3712 Statistically analysis appropriate 41 013 Results reported and clear 41 014 Results reported related to hypothesis and literature 41 015 Limitations reported 32 916 Conclusions do not go beyond limit of data and results 41 017 Findings able to be generalised 0 4118 Implications discussed 40 119 Existing conflict of interest with sponsor 0 4120 Data available for scrutiny and reanalysis 0 41

Qualitative studies critical appraisal checklist (Pearson, 2004)1 Congruity between stated philosophical perspective and research

methodology2 1

2 Congruity between methodology and research question orobjectives

3 0

3 Congruity between methodology and methods used to collect data 3 04 Congruity between methodology and representation and analysis of

data3 0

5 Congruity between methodology and interpretation of results 3 06 There is a statement locating the researcher culturally or

theoretically0 3

7 The influence of the researcher on the research, and vice-versa isaddressed

0 3

8 Participants and their voices are adequately represented 2 19 Ethical according to current criteria, evidence of ethical approval 3 010 Conclusions drawn flow from analysis or interpretation of data 3 0

904 V. Pitt et al. / Nurse Education Today 32 (2012) 903–913


statistical methods of correlational and regression analysis (seeTable 3). It was also noted that only one study (Cheung and Au,2011) explored clinical performance measures as a variable. Second-ly, factors were identified which reported a significant or non-significant impact on academic performance, clinical performance orattrition (see Table 4). Lastly these factors were grouped into fourmajor categories: demographic, academic, cognitive and personality/behaviour (see Table 5). Each category will be presented in terms ofthe relationship to performance and attrition.

Demographic FactorsDemographic factors describe the characteristics of the students and

included age, gender, ethnicity and employment status. No studiesexplored demographic factors and clinical performance measures.

Age. Five studies found that older students' had better academic per-formance than younger students. This was noted in the first year ofstudy in the UK (n=638, mean age of 24.89 years) (Donaldson, et al.,2010), in science courses in Australia (n=267, mean age of 25 years)(Salamonson and Andrew, 2006), in New Zealand students(b20 years, n=323; >20 years, n=296) (van Rooyen, et al., 2006)

and in the NCLEX-RN in the US (Daley et al., 2003; Harris, 2006;Vandenhouten, 2008).

Conversely, four studies reported non-significant correlationsbetween age and academic performance. This findingmay be explainedin part by the younger sample (mean age 20.18) (Ali and Naylor, 2009),the purposeful demographic sampling (first year English as secondlanguage population) (Salamonson et al., 2008), inclusion of full timestudents only (Dante et al., 2011); or a focus on successful graduates(Yin and Burger, 2003).

Younger students in the UK were also found to be more likely toleave nursing programs than older students (Anionwu et al., 2005;Pryjmachuk et al., 2009). In the US the impact of age on attritionhas not been reported on in the last decade. A limitation in the explo-ration of age was the lack of consistency across studies in defining theage of the older student.

Gender. Three studies foundno correlationbetweengender andacademicperformance. These included the outcomes of program performance inItaly (n=117, 29.9% male) (Dante, et al., 2011), science course resultsin Australia (11%male) (Salamonson, et al., 2009) and first time passingthe NCLEX-RN in the US (9% male) (Harris, 2006). However, femalediploma nursing students in Pakistan performed significantly better

Table 3General description of included papers.

Author(s) and year Country Sample n Analysis Design

BN AD Descriptive Correlational Regression Other

1 Alden (2008) US X X 370 X X X Retrospective cross sectional2 Ali and Naylor (2009) Pakistan X 628 X X Exploratory correlational3 Andrew et al. (2009) Aust X 112 X Factor analysis Psychometric analysis4 Anionwu et al. (2005) UK X X 1808 X X Longitudinal cohort5 Bowden (2008) UK X 46 Qualitative Nvivo Questionnaire and interview6 Bowles (2000) US X 65 X X Correlational7 Cheung and Au's (2011) HK X 30 X Experimental8 Daley et al. (2003) US X 224 X X Ex post facto9 Dante et al. (2011) Italy X 117 X X Retrospective multicentre10 Donaldson et al. (2010) UK X 638 X X Descriptive interpretive11 Ellis (2006) US X 137 X X Program evaluation12 Giddens and Gloeckner (2005) US X 218 X Discriminant variance Ex post facto13 Gilmore (2008) US X 218 X X Retrospective correlational14 Harris (2006) US X 167 X X X Descriptive inferential15 Higgins (2005) US N/S N/S 214 X Ex post facto16 Hoffman (2006) US X 437 X X ANOVA Descriptive correlational17 Jones and Morris (2007) US X 104 X Longitudinal correlational18 Lin et al. (2003) Taiwan X 177 X X Correlational19 McCarey et al. (2007) UK X 154 X ANOVA Quantitative20 McLaughlin et al. (2008) UK N/S N/S 384 X MANOVA Longitudinal quantitative21 McLaughlin et al. (2010) UK X 384 X X MANOVA Longitudinal quantitative22 Moore (2008) US X 208 X X X Quantitative23 Murray et al. (2008) US X X 68/69 X Longitudinal descriptive24 Newton et al. (2009) US X 127 X Exploratory descriptive25 Newton and Moore (2009) US X 107 X Exploratory descriptive26 Newton et al. (2007) US N/S N/S 164 X Exploratory descriptive27 Nibert et al. (2008) US X X 2346/3459 X Chi-square Descriptive comparative28 Pryjmachuk et al. (2009) UK X 1259 X Chi-square Retrospective cohort29 Rochford et al. (2009) UK X 79 X Cross sectional survey30 Rudel (2006) US X 12 Phenomenology Phenomenology31 Salamonson and Andrew (2006) Aust X 267 X X ANOVA Prospective correlational32 Salamonson et al. (2008) Aust X 273 X X Factor analysis Prospective correlational33 Salamonson et al. (2009) Aust X 126 X X X Prospective correlational34 Sanner and Wilson (2008) US X 3 Inductive analysis Qualitative in depth interviews35 Sayles et al. (2003) US X 68 X X Correlational36 Seldomridge and DiBartolo (2004) US X 186 X X X Retrospective correlational37 Shelton (2003) US X 458 X ANOVA Cross sectional38 Shirrell (2008) US X 173 X X Retrospective39 Tipton et al. (2008) US X 385 X Chi-square Retrospective40 Uyehara et al. (2007) US X 280 X X Correlational41 Vandenhouten (2008) US X 296 X X X Retrospective42 van Rooyen et al. (2006) NZ X 619 X Exploratory correlational43 Wood et al. (2009) US X 106 X X ANOVA Mixed method — descriptive44 Yin and Burger (2003) US X 325 X X X Chi-square Retrospective correlational

Key: Aust = Australia; HK = Hong Kong; NZ = New Zealand; BN = baccalaureate level programs; AD = associate degree level programs; N/S = not stated.

905V. Pitt et al. / Nurse Education Today 32 (2012) 903–913


(pb0.0001, 27.1%male) thanmales in a second and third year licensingexam (Ali and Naylor, 2009).

Gender was identified as a strong predictor of attrition in three UKstudies. A longitudinal study (n=1808, 20% male) of nursing studentsidentified that males were less likely than females to remain in a nurs-ing program (Anionwu, et al., 2005). This finding was supported by

both Pryjmachuk et al.'s (2009) and McLaughlin et al. (2010) studies,which found that males were twice more likely to withdraw thanfemales.

Ethnicity. Three studies explored the association between English as asecond language (ESL) or ethnicity and academic performance. An

Table 4List of factors related to literature addressing performance and attrition.

Factors Academic performance Clinical performance Attrition

Age Significant impactDonaldson, et al. (2010), Vandenhouten (2008),Salamonson and Andrew (2006),van Rooyen et al. (2006), Harris (2006)and Daley et al. (2003)Non-significant impactAli and Naylor (2009), Salamonson et al. (2008),Dante et al. (2011) and Yin and Burger (2003)

Significant impactAnionwu et al. (2005) andPryjmachuk et al. (2009)

Gender Significant impactAli and Naylor (2009)Non-significant impactSalamonson et al. (2009), Dante et al. (2011)and Harris (2006)

Significant impactAnionwu et al. (2005),Pryjmachuk et al. (2009)and McLaughlin et al. (2010)

English as secondlanguage

Significant impactSalamonson et al. (2008),Sanner and Wilson (2008),Anionwu et al. (2005)

Hours of part-timeemployment

Significant impactSalamonson and Andrew (2006), Salamonson et al. (2009),Dante et al. (2011) and Rochford et al. (2009)Non-significant impactMoore (2008)

Preadmission: Secondaryschool performance

Significant impactAli and Naylor (2009) and van Rooyen et al. (2006)Non-significant impactYin and Burger (2003)

Significant impactPryjmachuk et al. (2009)

Preadmission: Prerequisite courseperformance

Significant impactGilmore (2008), Alden (2008), Higgins (2005),Seldomridge and DiBartolo (2004), Shirrell (2008)and Yin and Burger (2003)

Preadmission exam Significant impactNewton et al. (2009), Tipton et al. (2008),Murray et al. (2008), Gilmore (2008),Vandenhouten (2008), Uyehara et al. (2007),Newton et al. (2007), Alden (2008),Sayles et al. (2003) and Daley et al. (2003)

Significant impactHiggins (2005)Non-significant impactNewton and Moore (2009)

First semester GPA Significant impactNewton et al. (2007), Lin et al. (2003)and McCarey et al. (2007)

Science courseperformance

Significant impactUyehara et al. (2007) and van Rooyen et al. (2006)Non-significant impactHarris (2006) and Shirrell (2008)

Significant impactUyehara et al. (2007)

Nursing courseperformance

Significant impactHiggins (2005), Shirrell (2008), Tipton et al. (2008),Seldomridge and DiBartolo (2004) and Uyehara et al. (2007)Non-significant impactLin et al. (2003)

Exit examinations Significant impactDaley et al. (2003), Uyehara et al. (2007),Higgins (2005), Nibert et al., (2008)and Seldomridge and DiBartolo (2004)

Critical thinking Significant impactShirrell (2008), Hoffman (2006),Giddens and Gloeckner (2005) and Bowles (2000)

Significant impactJones and Morris (2007)and Ellis (2006)

Personality Significant impactWood et al. (2009) and McLaughlin et al. (2008)

Anxiety Significant impactCheung and Au (2011)

Self-efficacy Significant impactMcLaughlin et al. (2008) and Andrew et al. (2009)

Support Seeking Significant impactMoore (2008)

Significant impactShelton (2003), Bowden (2008)and Rudel (2006)

Academic engagement Significant impactSalamonson et al. (2009) and McCarey et al. (2007)

Non-significant impactAnionwu et al. (2005)



Australian prospective correlational study concluded that first year ESLbaccalaureate nursing (BN) students with higher levels of assimilationto the English-language achieved significantly (pb0.001, n=273)higher grades within four first semester courses (Salamonson, et al.,2008). Yet, American ESL nursing students (n=3) who experiencedcourse failure felt that language was not the primary reason for theirfailure, but attributed their academic difficulties to discrimination andstereotyping (Sanner and Wilson, 2008).

In contrast, a large study (n=1808) conducted in the Thames ValleyUniversity (UK) explored records of students entering the CommonFoundation Program (CFP) over 3 years and found that ethnic minoritystudents had significantly better (pb0.001) academic performancethan UK born students (Anionwu, et al., 2005). These results may beexplained by the classification of ethnicity. The sample included: ethnicminority students (English speaking countries) (62%), UKborn students(28%) and ESL (10%) (Anionwu, et al., 2005). In bivariate tests of successit was noted that 30% of ESL students did not meet academic standardsand withdrew during the CFP (Anionwu, et al., 2005). This study high-lights the importance of exploring not only the country of birth, butalso the ESL status of students. No studies were found that examinedthe impact of ethnicity on attrition.

Employment Status. An issue confronting nursing education is theimpact of part-time employment on academic performance. Four stud-ies exploring BN students noted that full time students working morethan 16 h per week had poorer academic performance in individualcourses within Australia (Salamonson and Andrew, 2006; Salamonson,et al., 2009), whole programs within Italy (Dante, et al., 2011) andcourse performance in the UK (Rochford, et al., 2009). Whereas, no sig-nificant relationship was found between the hours of employment andacademic performance in a US associate degree program (Moore,2008). The type of employment, nursing or non-nursing related, didnot alter the negative impact that employment had on academic perfor-mance (Salamonson and Andrew, 2006; Salamonson, et al., 2009). As nostudies were identified that examined the impact of employment statuson attrition or clinical performance, this should be a focus of futureinvestigations.

Academic FactorsAcademic factors include students' admission qualifications and

within program indicators. No studies explored academic factors andclinical performance measures.

Admission Qualifications. This factor considers how students' academicperformance may be impacted by admission qualifications. As admis-sion qualifications are used to determine eligibility for enrolment it isnot surprising that this factor has dominated the literature. Admis-sion qualifications include students' secondary school performance,performance in prerequisite university courses (specifically US) andperformance in pre-admission examinations (specifically US).

Secondary school academic performance is the traditional admissionpathway to tertiary education. Three studies studied secondary schoolperformance and academic performance in nursing programs. In

Pakistan students with better academic performance in secondaryschoolwere found to have a significantly (pb0.001, n=628) better per-formance in yearly nursing licensing examinations (Ali and Naylor,2009). An exploratory correlational study inNewZealand also identifieda significant positive correlation (pb0.01, n=625) between marks insecondary school bioscience courses and academic performance intwo nursing bioscience assessments (year one r=0.26, year twor=0.316) (van Rooyen, et al., 2006). In contrast a US associate degreenursing program identified that high school graduates GPA (n=325)had no correlation with passing the NCLEX-RN exam (Yin and Burger,2003).

Admission into preregistration nursing programs via prerequisitecourses is a common practice in the US, and is a major focus of theliterature. Five US studies demonstrated a significant correlationbetween performances in science based prerequisite courses andperformance throughout a program, including NCLEX-RN readiness(p=0.015), passing the NCLEX-RN (r=0.171), performance in firstyear (pb0.0001) and program completion (r=0.152) (Alden, 2008;Gilmore, 2008; Higgins, 2005; Seldomridge and DiBartolo, 2004;Shirrell, 2008; Yin and Burger, 2003).

Preadmission examinations are mostly used in the US. Theseexaminations are developed and distributed by various companiesand generally assess mathematics, science, reading, English and com-prehension abilities. Five preadmission examinations were used inthe literature. These included the Test of Essential Academic Skills(TEAS) (Newton et al., 2009, 2007), The Nurse Entrance Test (NET)(Alden, 2008; Sayles et al., 2003; Tipton et al., 2008), The Health Ed-ucation Systems Inc. (HESI) which also includes critical thinking andpersonality style (Murray et al., 2008), the National League for Nursing(NLN) admission test (Uyehara et al., 2007) and The American CollegeTesting (ACT) (Gilmore, 2008). All these examinations were found tohave a positive correlation to academic measures in preregistrationprograms. Only the NET and ACT were noted to have a relationshipto NCLEX-RN success. Sayles et al. (2003) reported that the compositeNET score and ACT scores were significantly (p=0.001, n=68) relatedto NCLEX-RN success. Vandenhouten (2008) and Daley, et al.'s (2003)studies both found that ACT scores correlated with performance onthe NCLEX-RN.

Three studies examined admission qualifications and attritionwith conflicting results. Pryjmachuk, et al.'s (2009) retrospective studyof UK diploma students (n=1259) noted that those with minimalentry qualifications were less likely to complete the diploma. In relationto preadmission exams Higgins (2005) reported that students perfor-mance in the subscales of reading (r=0. 124), science (r=0.184) andmath (r=0.129) had a significant relationship to program completion.Yet, this contrasts recent research, which concluded that the TEAS pre-admission examination was not a predictor of attrition (Newton andMoore, 2009).

Within Program Indicators. Based on the findings that students withhigher admission qualifications had better academic performance itwould be assumed that these students would continue with a high-quality performance. The factor of within program indicators ex-amines the relationship between students' academic performanceat early and later stages of the nursing program. Within programindicators included factors such as students' first semester grades,performance in specific courses or assessments and exit examina-tions (US).

The effectiveness of first semester GPA as a predictor of successwas reported in three studies. First semester GPA was found to be apredictor of success (p=0.043) in the licensing readiness exam inboth the US (Newton, et al., 2007) and Taiwan (r=0.150, p=0.001)(Lin et al., 2003), as well as third year performance (pb0.001, n=154)in UK diploma students (McCarey, et al., 2007).

Four studies examined science course performance. Pathophysiologycourse performance was a significant predictor (pb0.001) of US

Table 5Four major categories identified in the literature.

Demographic factors Academicfactors

Cognitive Personality/behaviour

AgeGenderEnglish assecond languageHours of part-timeemployment

AdmissionqualificationsWithin programindictors

Criticalthinkingskills

PersonalityAnxietySelf-efficacySupport seekingAcademic engagement(tutorial/lecture attendance,homework completion)



students remaining in a BN program (Uyehara, et al., 2007). A NewZealand study found that students' performance in a first year biosci-ence assessment had significant correlation to performance in a secondyear bioscience assessment (van Rooyen, et al., 2006). Yet Harris (2006)(n=167) and Shirrell (2008) (n=173) reported no correlation be-tween science course performance and first time success in theNCLEX-RN in associate degree students. These results may be attributedto the NCLEX-RN examination assessing much more than just scienceknowledge.

One of the strongest within program indicators for predictingNCLEX-RN success was students' performance in nursing coursesthroughout a program. This correlation was noted in US associatedegree students (Higgins, 2005; Shirrell, 2008; Tipton, et al., 2008)and BN students (Seldomridge and DiBartolo, 2004; Uyehara, et al.,2007). A weak correlation (r=0.136 – r=0.035,pb0.05,n=177) wasalso noted in Taiwan associate degree nursing students in the NQEX-RPN (equivalent to NCLEX-RN) (Lin, et al., 2003).

Exit examinations are used within the US in an attempt to predictstudents' readiness for the NCLEX-RN. Exit examinations' main aimsare to determine if students require remediation prior to sitting theNCLEX-RN exam. Three readiness examinations were used in theliterature; all were found to predict NCLEX-RN success. These exami-nations included the Mosby Assess test (p=0.003) (Daley, et al.,2003; Uyehara, et al., 2007), the HESI exit exam which is mostlyused in associate degree programs (Higgins, 2005; Nibert et al.,2008) and the NLN exit exam (Seldomridge and DiBartolo, 2004).

The correlation between attrition and within program indicatorswas noted in only one Hawaiian study. Uyehara et al.'s (2007) studyof BN students reported that poor performance in pathophysiologycourses was significantly correlated (pb0.0001, n=280) to attrition.

Cognitive FactorsCognitive factors relate specifically to students' ability to process

information, problem solve and reason logically (Lumsden et al.,2005). The factor of critical thinking was explored in the literature. Nostudies explored critical thinking and clinical performance measures.

Critical Thinking. There is a general consensus that critical thinking isan essential component of skilled nursing practice (Jones and Morris,2007; Shirrell, 2008). The examination of critical thinking in the liter-ature is challenging as there are a variety of tests used to measure thisattribute. A study applying the Critical Thinking Process Test (CTPT)prior to graduation (n=437) found a significant relationship to criti-cal thinking scores and passing the NCLEX-RN (Hoffman, 2006).Shirrell (2008) found (n=173) that critical thinking (CollegiateAssessment of Academic Proficiency (CAAP)) alone had no associationwith success on NCLEX-RN. However, when combined in a modelusing multiple regression nursing GPA, science GPA and CAAP scoreswere associated (pb0.001) with success in the NCLEX-RN (Shirrell,2008). Giddens and Gloeckner's (2005) study (n=218) used theCalifornia Critical Thinking Skills Test (CCTST) and California CriticalThinking Disposition Inventory (CCTDI) at entry and exit of a BN pro-gram. No relationship with entry CCTDI scores and passing or failingthe NCLEX-RN was found yet, entry CCTST and entry and exit CCTDIscores were significantly higher for those who passed the NCLEX-RN.Using discriminate analysis Giddens and Gloeckner also found thatCCTST, CCTDI scores combined with nursing GPA were 98% accuratein predicting those who passed the NCLEX-RN, but were less preciseat predicting failures. Using a correlational design CCTST critical think-ing scores were also used in a smaller study (n=65) at the end of theprogram and were found to have a significant positive correlation(p=0.00) to students' program GPA (Bowles, 2000).

Attrition from programs was associated with low levels of criticalthinking skills in two studies. Jones and Morris (2007) found that stu-dents with higher critical thinkingmeasures using the Critical ThinkingAssessment (CAT) were more likely (pb0.01, n=104) to complete

their associate degree in 2 years than those with lower scores.Using the critical thinking appraisal section of the NET, Ellis(2006) reported that studentswith higher scores on entering the diplo-ma program were more likely to remain in the program after 1 year(p=0.011).

Personality and Behaviour FactorsThe exploration of personality and behaviours as predictors of

academic performance and attrition is becoming increasingly appar-ent in the nursing literature. These include personality, anxiety, self-efficacy, support seeking and academic engagement.

Personality. Two studies explored personality and academic perfor-mance. A descriptive study of 106 US nursing students examiningperceived locus of control noted that students with a higher measureof external locus of control (perceiving that external factors controlachievement) had significantly (p=0.034) lower grades in a firstyear medical/surgical course (Wood et al., 2009). No relationshipwas found between internal locus of control and grades. McLaughlinet al.'s (2008) longitudinal study of UK students (n=384) appliedEysenck Personality Questionnaire on enrolment and found thatthose with a higher extraversion score had lower overall academicperformance (p=0.001). Where students with a higher psychoticismpersonality score were more likely (p=0.003) to withdraw fromtheir nursing program (McLaughlin, et al., 2008). A limitation of thisstudy was the younger (mean age 20.7 years) and female dominated(9.1% of males) sample population.

Anxiety. The impact that anxietymay have on a nursing student's abilityto learn was explored in one paper. The only paper that used clinicalperformance measures as an outcome, Cheung and Au's (2011) studyof 30 third and fourth year nursing students in Hong Kong used videosasmood inducers to determine if higher levels of anxietywere linked toclinical performance. Using the skill of simulated suture removal, stu-dents with higher levels of anxiety made significantly (pb0.05) moreerrors in their clinical performance. The major limitation of this studywas the small sample size.

Self-efficacy. Twopapers explored self-efficacy in differentways. Andrewet al.'s (2009) pilot study examined mathematics self-efficacy in 154second year nursing students and found that a higher mathematicsself-efficacy was directly related to a better performance in a mathemat-ics assessment. McLaughlin et al. (2008) studied students' occupationalself-efficacy (confidence in successfully performing specialised duties)and found that UK nursing students with a higher occupational self-efficacy had a better overall performance (p=0.048, n=35) in a diplo-ma in nursing.

Support Seeking. Students' academic and social support seeking behav-iours were demonstrated to have an impact on both progression andattrition.Moore (2008) found that US studentswithmore social supportfrom either families, friends, university and community during theirstudies had better overall GPA (pb0.000). The relationship betweensupport seeking behaviours and attrition was explored in three studies.Associate degree of nursing students (n=458)with a higher perceptionof faculty support, psychological support and functional support wereless likely (pb0.05) to withdraw from the program (Shelton, 2003).This was supported by Bowden's (2008) who interviewed eight UKgraduates who seriously considered leaving their nursing program, sixof whom identified the important role of tutors in supporting themboth clinically and academically. Bowden also noted that only threestudents actually accessed the support services provided by the univer-sity. In a phenomenological study, 12 mature aged students reportedchoosing to remain in the program because of the support gained fromsignificant others, peers and others (Rudel, 2006).



Academic Engagement. The term academic engagement was investi-gated in two studies that explored student behaviour of studentclass attendance (McCarey, et al., 2007) and completion of homework(Salamonson, et al., 2009). McCarey et al.'s (2007) research analysedstudents' (n=154) record of attendance over a three year period.They found a significant negative correlation (pb0.001) betweennon-attendance and academic performance in only one written as-sessment item out of seven in a three year period. How classattendance was collected or if attendance was compulsory was notreported. Salamonson et al.'s (2009) investigation (n=126) ofnon-compulsory lecture attendance andmarked homework comple-tion, found that although lecture attendance (p=0.011) did impacton performance in a pathophysiology course in a second year BNprogram, homework completion was the strongest predictor(pb0.001). The fact that homework completion received a markwhich accounted to the final grade must be taken into considerationwith these results.

In relation to attritionAnionwuet al. (2005)noted that the number ofdays a nursing student (n=1808) was absent from tutorials over thecourse of the UK program did not predict whether a student completedthe program.

Discussion

The Nursing Undergraduate Retention and Success (NURS) modelrecognises that many factors have a potential impact on undergraduatenursing students' progression and completion (Jeffreys, 2004, 2007).Focused on the US experience, success in this model is passing theNCLEX-RN exam yet, the idea underpinning the model of examiningmultiple factors is applicable to any nursing program. This review high-lights factors that have demonstrated a relationship to academic perfor-mance and attrition in many programs, universities should use thesefindings to guide their exploration of progression and attrition. Amajor gap in the literature is the exploration of factors which impacton students' clinical performance measures. This may be related to thedifficulty in the evaluation and measurement of clinical competence(Cowan, et al., 2005; Norman, et al., 2002). Yet, the practical nature ofnursingwarrants an immediate examination of factors that may impacton students' clinical performance.

Academic Performance

Unlike Jeffreys' (2004, 2007)research which focused primarily onstudent retention and attrition, this review explored academic perfor-mance outcomes, not only at the completion of a program but alsothroughout the program. Like the NURSmodel (Jeffreys, 2004) severalfactors were identified as impacting on performance and need to beconsidered when conducting future research. These include:

Demographic factors: Traditionally students enrol in preregistrationeducation after completing secondary education at the age of 17 to18 years of age. However, there has been an increase in the numberof older students enrolling into preregistration education. The impe-tus to recruit more mature students into nursing programs issupported by findings that although not all significant demonstratethat being older does not impact negatively on performance.Nursing has traditionally been a female dominated profession,although in the last 40 years the number of males has increased.Small numbers of males within research cohorts are a commonlyreported limitation (Ali and Naylor, 2009; Rochford, et al., 2009)and may account for the lack of exploration in relation to academicperformance. Males entering nursing require additional support asthey continue to have poorer academic performance compared to fe-male students.

The exploration of ethnicity within the literature used terms such asminority, ethnicity and English as a second language (ESL). Currentresearch into the impact of this factor has been hindered by smallnumbers of ESL students, yet it remains an area that requires furtherexploration. Nursing education programswould benefit fromongoinginvestigation of ESL students' performance in preference to collectingdata based only on students' country of birth.The investigation of employment status emphasised the emergingissue of the impact of paidwork on performance in higher education(Curtis and Shani, 2002; Holmes, 2008). This review identified thatworking 16 h per week or more in paid employment negativelyinfluenced full time students' academic performance.Academic factors: The traditional time of entry for most preregistra-tion programs is following secondary school and based on matricu-lation qualifications. Internationally universities and colleges havebroadened admission qualifications for entry to nursing programsto include students' secondary school performance, prerequisiteuniversity courses (specifically US) and pre-admission examinations(specifically US). It is clear that students who perform betterprior to admission or on preadmission examinations will havebetter academic performance within the program. Therefore itis important to establish and research the effectiveness of aca-demic supports for those with lower admission qualifications.The limitation of these findings is that they are dominated by re-search conducted in the US. A need for further exploration byother countries is required with a variety of academic perfor-mance outcome measures.Cognitive factors: Possessing the ability to process informationand reason effectively has been highlighted as an essential qualitywithin the profession of nursing (del Bueno, 2005; Levett-Jones etal., 2010). This review suggests that there is a possible relationshipbetween nursing students' critical thinking skills and academicperformance. These findings necessitate further exploration ofcritical thinking, specifically outside the US.Personality and behaviour: Personality has been widely explored inthe broader university student population (Chamorro-Premuzic andFurnham, 2003; Dollinger et al., 2008) and the findings from thisreview indicate that it would be beneficial to continue to explorethis relationship in nursing students.Self-efficacy can be described in relation to an individual's motiva-tion to apply effort. An individual who has high self-efficacy mayperceive failure to be a result of insufficient work and consequent-ly applies more effort in future work (McLaughlin, et al., 2008). Incontrast, an individual with a low level of self-efficacy becomesfocused on failures and is not motivated in the application of fu-ture effort (McLaughlin, et al., 2008). Although, higher levels ofself-efficacy correlate to better academic performance, it is ac-knowledged that consistent measures are a limitation of the find-ings and need to be a consideration in any future research.Academic engagement has been explored in relation to class at-tendance and completion of homework and although the findingssuggest there may be a relationship between engagement andperformance further exploration is required, especially in light ofincreasing e-learning approaches.

Attrition

Jeffreys' (2004) model outlines numerous factors that impact onstudents' completion of nursing programs, many of which havebeen investigated in literature. Preregistration programs interested in



investigating factors that may contribute to attrition should considerthe following factors:

Demographic factors: Younger students are more likely to leavenursing programs, yet there is an obvious gap in the explorationof this demographic over the last 10 years in the US. In relation togender, it is recognised thatmen struggle to remainwithin nursingeducation. This requires further exploration to determine if anon-supportive culture exists that may be impacting on progres-sion of suitable candidates (McLaughlin, et al., 2010). There hasbeen a lack of research into ethnicity and attrition and althoughfinancial stress can lead to attrition (Last and Fulbrook, 2003), theimpact of employment status on attrition has yet to be explored.Academic and cognitive factors: There is an indication that betterqualifications on admission relate to less attrition however, thisfactor has not been widely explored within the literature in thelast decade. This review also identified that students with higherlevels of critical thinking skills are more likely to stay, yet thisrequires further examination.Personality/behaviours: Although research acknowledges a correla-tion to academic performance the associationwith attrition is limited.Support seeking behaviour is one area that has attracted some atten-tion in the literature. It has been noted that levels of stress increase asstudents' progress through a program (Burnard et al., 2008; Lo,2002). These findings show that students who seek support are lesslikely to withdraw, which validates the continual drive within pro-grams to encourage students to engage in support programs.

Limitations

The limitation of this review is the heterogeneity evident in the sam-ple populations of the studies reviewed. Each study selectedparticipants from their ownprogram resulting in a range of participants'age, gender, ethnicity and length of program. Studies included associatediploma and baccalaureate programs of various lengths and contentfrom a range of countries. This is acknowledged as limiting thegeneralisability of the findings to other preregistration nursing

programs. However, the aim of this review was to identify factorswhich preregistration nursing programs could use to guide explo-ration of progression and attrition.

Conclusion

As universities continue to increase nursing student numbers tomeet the demand for an expanded workforce, it is essential to identifyfactors which have the greatest impact on student progression andattrition. Research has focused primarily on factors that impact on nurs-ing students' academic performance (36 studies), with fewer studies(12) exploring factors that impact on attrition and only one study ex-ploring impact on clinical performance. This integrative review hasfound that students' academic performance is affected by many factorsincluding: age, gender, English as a second language, employment sta-tus, admission qualifications, within program performance, criticalthinking skills, personality, self-efficacy and academic engagement.The data show that attrition is related to: age, gender, admission quali-fications, science course performance through the program, criticalthinking skills, support seeking and academic engagement. Therewere several areas that were found to have a significant relationshipto academic performance but were not explored in relation to attrition,such as English as a second language, employment status, within pro-gram performance, personality and self-efficacy. The absence of re-search on the factors that impact students' clinical performance is aconcern and considering the practical nature of nursing is an area thatclearly requires immediate exploration.

Conflict of Interest

No conflict of interest has been declared by the authors.

Funding

This research received no specific grant from any funding agencyin the public, commercial, or not-for-profit sectors.



Autho

r(s)

andyear

1.Aim

and

objectives

2. Research

questio

n

3. Variables

stated

4. Variables

clear

5. Design

6. Metho

dap

prop

riate

7. Instrumen

tstested

8. Sample

describe

d

9. Error

10.

Ethics

11.

Piloted

12.

Ana

lysis

adeq

uate

13.

Results

clear

14.R

/thy

pothesis

15.

Limita

tions

16.

Conc

lusion

s17

.Gen

eralise

18.

Implications

19.

Confl

ict

20.

Accessible

data

1Alden

(200

8)X

XX

XX

XX

XX

XX

XX

XX

XX

2Alian

dNay

lor(2

009)

XX

XX

XX

XX

XX

XX

XX

XX

X3

And

rew

etal.(20

09)

XX

XX

XX

XX

XX

XX

XX

XX

X4

Anion

wuet

al.(20

05)

XX

XX

XX

XX

XX

XX

XX

XX

X5

Bowles(2

000)

XX

XX

XX

XX

XX

XX

XX

XX

6Ch

eung

andAu's(2

011)

XX

XX

XX

XX

XX

XX

XX

XX

X7

Daley

etal.(20

03)

XX

XX

XX

XX

XX

XX

XX

X8

Dan

teet

al.(20

11)

XX

XX

XX

XX

XX

XX

XX

XX

X9

Don

alds

onet

al.(20

10)

XX

XX

XX

XX

XX

XX

X10

Ellis

(200

6)X

XX

XX

XX

XX

XX

XX

XX

11Gidde

nsan

dGloeckn

er(2

005)

XX

XX

XX

XX

XX

XX

XX

12Gilm

ore(2

008)

XX

XX

XX

XX

XX

XX

XX

XX

X13

Harris(2

006)

XX

XX

XX

XX

XX

XX

X14

Higgins

(200

5)X

XX

XX

XX

XX

XX

XX

XX

XX

XX

15Hoffm

an(2

006)

XX

XX

XX

XX

XX

XX

XX

16Jone

san

dMorris(2

007)

XX

XX

XX

XX

XX

XX

XX

XX

XX

17Linet

al.(20

03)

XX

XX

XX

XX

XX

XX

XX

XX

18McC

arey

etal.(20

07)

XX

XX

XX

XX

XX

XX

X19

McLau

ghlin

etal.(20

08)

XX

XX

XX

XX

XX

XX

XX

X20

McLau

ghlin

etal.(20

10)

XX

XX

XX

XX

XX

XX

XX

XX

21Moo

re(2

008)

XX

XX

XX

XX

XX

XX

XX

XX

22Murrayet

al.(20

08)

XX

XX

XX

XX

XX

XX

XX

X23

New

tonet

al.(20

09)

XX

XX

XX

XX

XX

XX

XX

XX

XX

24New

tonan

dMoo

re(2

009)

XX

XX

XX

XX

XX

XX

XX

XX

X

25New

tonet

al.(20

07)

XX

XX

XX

XX

XX

XX

XX

X26

Nibertet

al.(20

08)

XX

XX

XX

XX

XX

XX

XX

XX

X27

Pryjmachu

ket

al.(20

09)

XX

XX

XX

XX

XX

XX

XX

XX

X28

Roch

ford

etal.(20

09)

XX

XX

XX

XX

XX

XX

XX

XX

29Sa

lamon

sonan

dAnd

rew

(200

6)X

XX

XX

XX

XX

XX

XX

XX

X

30Sa

lamon

sonet

al.(20

08)

XX

XX

XX

XX

XX

XX

XX

XX

X31

Salamon

sonet

al.(20

09)

XX

XX

XX

XX

XX

XX

XX

X32

Sayles

etal.(20

03)

XX

XX

XX

XX

XX

XX

XX

XX

X33

Seldom

ridg

ean

dDiBartolo

(200

4)X

XX

XX

XX

XX

XX

XX

XX

XX

34Sh

elton(2

003)

XX

XX

XX

XX

XX

XX

XX

XX

35Sh

irrell(2

008)

XX

XX

XX

XX

XX

XX

XX

XX

XX

36Tipton

etal.(20

08)

XX

XX

XX

XX

XX

XX

XX

XX

X37

Uye

hara

etal.(20

07)

XX

XX

XX

XX

XX

XX

XX

XX

38Van

denh

outen(2

008)

XX

XX

XX

XX

XX

XX

XX

39va

nRo

oyen

etal.(20

06)

XX

XX

XX

XX

XX

XX

X40

Woo

det

al.(20

09)

XX

XX

XX

XX

XX

XX

XX

XX

XX

41Yinan

dBu

rger

(200

3)X

XX

XX

XX

XX

XX

XX

XX

X

App

endix1.

Quan

titative

studies

critical

appr

aisalc

hec

klist

(Bow

ling,

2009

)



Criteria Rudel (2006) Sanner and Wilson (2008) Bowden (2008)

1 Congruity between stated philosophical perspective and research methodology X X X2 Congruity between methodology and research question or objectives X X X3 Congruity between methodology and methods used to collect data X X X4 Congruity between methodology and representation and analysis of data X X X5 Congruity between methodology and interpretation of results X X X6 There is a statement locating the researcher culturally or theoretically7 The influence of the researcher on the research, and vice-versa is addressed8 Participants and their voices are adequately represented X X9 Ethical according to current criteria, evidence of ethical approval X X X10 Conclusions drawn flow from analysis or interpretation of data X X X

Appendix 2. Qualitative studies critical appraisal checklist (Pearson, 2004)

References

Alden, K., 2008. Predictors of Early Academic Success and Program Completion amongBaccalaureate Nursing Students. Adult and Community College Education, NorthCarolina.

Ali, P., Naylor, P., 2009. Association between academic and non-academic variables andacademic success of diploma nursing students in Pakistan. Nurse Education Today30 (2), 157–162.

American Association of Colleges of Nursing, 2009. Nursing Shortage: Fact Sheet:Washington, D.C.

Andrew, S., Salamonson, Y., Halcomb, E.J., 2009. Nursing students' confidence in medi-cation calculations predicts math exam performance. Nurse Education Today 29(2), 217–223.

Anionwu, E.N., Mulholland, J., Atkins, R., Tappern, M., Franks, P.J., 2005. Diversity, Attri-tion and Transition in to Nursing: The DATING Project Final Report. Thames ValleyUniversity, London.

Bowden, J., 2008. Why do nursing students who consider leaving stay on their courses?Nurse Researcher 15 (3), 45–58.

Bowles, K., 2000. The relationship of critical-thinking skills and the clinical-judgmentskills of baccalaureate nursing students. Journal of Nursing Education 39 (8), 373.

Bowling, A., 2009. Research Methods in Health: Investigating Health and Health Ser-vices. Open University Press, Maidenhead.

Buchan, J., Seccombe, I., 2008. An Incomplete Plan: The UK Nursing Labour Market Re-view 2008. Royal College of Nursing United Kingdom, Edinburgh.

Burnard, P., Edwards, D., Bennett, K., Thaibah, H., Tothova, V., Baldacchino, D., et al.,2008. A comparative, longitudinal study of stress in student nurses in five coun-tries: Albania, Brunei, the Czech Republic, Malta and Wales. Nurse EducationToday 28 (2), 134–145.

Cameron, J., Roxburgh, M., Taylor, J., Lauder, W., 2011. An integrative literature reviewof student retention in programmes of nursing and midwifery education: why dostudents stay? Journal of Clinical Nursing 20, 1372–1382.

Chamorro-Premuzic, T., Furnham, A., 2003. Personality predicts academic perfor-mance: evidence from two longitudinal university samples. Journal of Researchin Personality 37 (4), 319–338.

Chapman, R., Orb, A., 2000. The nursing students' lived experience of clinical practice.The Australian Electronic Journal of Nursing Education 5 (2) (15 pp.).

Chesser-Smyth, P.A., 2005. The lived experiences of general student nurses on theirfirst clinical placement: a phenomenological study. Nurse Education in Practice 5,320–327.

Cheung, R.Y.M., Au, T.K., 2011. Nursing students' anxiety and clinical performance.Journal of Nursing Education 50 (5), 286–289.

Cowan, D.T., Norman, I., Coopamah, V.P., 2005. Competence in nursing practice: a controver-sial concept — a focused review of literature. Nurse Education Today 25 (5), 355–362.

Curtis, S., Shani, N., 2002. The effect of taking paid employment during term-time on stu-dents' academic studies. Journal of Further and Higher Education 26 (2), 129–138.

Daley, L.K., Kirkpatrick, B.L., Frazier, S.K., Chung, M.L., Moser, D.K., 2003. Predictors ofNCLEX-RN success in a baccalaureate nursing program as a foundation for remedi-ation. Journal of Nursing Education 42 (9), 390.

Dante, A., Valoppi, G., Saiani, L., Palese, A., 2011. Factors associated with nursing stu-dents' academic success or failure: a retrospective Italian multicenter study.Nurse Education Today 31 (1), 59–64.

del Bueno, D., 2005. A crisis in critical thinking. Nursing Education Perspectives 5,278–283.

Department of Education Employment and Workplace Relations, 2009. Attrition Pro-gress and Retention Rates for Commencing Bachelor Students. DEEWR, Canberra.

Dollinger, S.J., Matyja, A.M., Huber, J.L., 2008. Which factors best account for academicsuccess: those which college students can control or those they cannot? Journalof Research in Personality 42 (4), 872–885.

Donaldson, J.H., McCallum, J., Lafferty, P., 2010. Can we predict successful completion ofthe common foundation programme at interview? Nurse Education Today 30 (7),649–656.

Ellis, S.O., 2006. Nurse entrance test scores: a predictor of success. Nurse Educator 31(6), 259–263.

Giddens, J., Gloeckner, G.W., 2005. The relationship of critical thinking to performanceon the NCLEX-RN®. Journal of Nursing Education 44 (2), 85.

Gilmore, M., 2008. Predictors of success in associate degree nursing programs. Teachingand Learning in Nursing 3 (4), 121–124.

Harris, M.S., 2006. Investigation of prerequisite science course performance and cumu-lative grade point average as predictors of success on the National Council Licen-sure Examination for Registered Nurses. Unpublished Ed.D., Tennessee StateUniversity, United States — Tennessee

Higgins, B., 2005. Strategies for lowering attrition rates and raising NCLEX-RN passrates. Journal of Nursing Education 44 (12), 541–547.

Hoffman, J.J., 2006. The relationships between critical thinking, program outcomes, andNCLEX-RN performance in traditional and accelerated nursing students.Unpublished Ph.D., University of Maryland, Baltimore, United States — Maryland

Holmes, V., 2008. Working to live: why university students balance full-time study andemployment. Education and Training 50 (4), 305–314.

Jeffreys, M.R., 2004. Nursing Student Retention: Understanding the Process and Makinga Difference. Springer Publisher, New York.

Jeffreys, M.R., 2007. Tracking students through program entry, progression, graduation,and licensure: assessing undergraduate nursing student retention and success.Nurse Education Today 27 (5), 406.

Jones, J.H., Morris, L.V., 2007. Evaluation of critical thinking skills in an associate degreenursing program. Teaching and Learning in Nursing 2 (4), 109–115.

Lacey, T., Wright, B., 2009. Occupational Employment Projections to 2018. MonthlyLabor Review Online 132 (11).

Last, L., Fulbrook, P., 2003. Why do student nurses leave? Suggestions from a Delphistudy. Nurse Education Today 23, 449–458.

Levett-Jones, T., Hoffman, K., Dempsey, J., Jeong, S., Noble, D., Norton, C., et al., 2010. The‘five rights’ of clinical reasoning: an educational model to enhance nursing stu-dents' ability to identify and manage clinically ‘at risk’ patients. Nurse EducationToday 30 (6), 515–520.

Lin, R., Fung, B., Hsiao, J.-K., Lo, H.-F., 2003. Relationship between academic scores andperformance on national qualified examination for registered professional nurses(NQEX-RPN). Nurse Education Today 23 (7), 492–497.

Lo, R., 2002. A longitudinal study of perceived level of stress, coping and self-esteem ofundergraduate nursing students: an Australian case study. Journal of AdvancedNursing 39 (2), 119–126.

Lofmark, A., Wikblad, K., 2001. Facilitating and obstructing factors for the developmentof learning in clinical practice: a student perspective. Journal of Advanced Nursing34 (1), 43–50.

Lumsden, M.A., Bore, M., Millar, K., Jack, R., Powis, D.A., 2005. Assessment of personalqualities in relation to admission to medical school. Medical Education 39,258–265.

McCarey, M., Barr, T., Rattray, J., 2007. Predictors of academic performance in a cohortof pre-registration nursing students. Nurse Education Today 27 (4), 357.

McLaughlin, K., Moutray, M., Muldoon, O.T., 2008. The role of personality and self-efficacy in the selection and retention of successful nursing students: a longitudinalstudy. Journal of Advanced Nursing 61 (2), 211–221.

McLaughlin, K., Muldoon, O.T., Moutray, M., 2010. Gender, gender roles and comple-tion of nursing education: a longitudinal study. Nurse Education Today 30 (4),303–307.

McMillan, J., 2005. Longitudinal surveys of Australian youth: course change and attri-tion from higher education Retrieved from www.acer.edu.au/documents/LSAY_lsay39.pdf.

Moore, J.A., 2008. Effect of outside employment on academic success among full-timeassociate degree nursing students. Unpublished Ph.D., Old Dominion University.

Murray, K.T., Merriman, C.S., Adamson, C., 2008. Use of the HESI Admission Assessment topredict student success. CIN: Computers, Informatics, Nursing 26 (3), 167–172.

National Health Workforce Taskforce, 2009. Health workforce in Australia and factors forcurrent shortages, April 2009Retrieved from http://www.nhwt.gov.au/documents/



NHWT/The%20health%20workforce%20in%20Australia%20and%20factors%20influencing%20current%20shortages.pdf.

Newton, S.E., Moore, G., 2009. Use of aptitude to understand Bachelor of Science inNursing student attrition and readiness for the National Council LicensureExamination-Registered Nurse. Journal of Professional Nursing 25 (5), 273–278.

Newton, S.E., Smith, L.H., Moore, G., Magnan, M., 2007. Predicting Early AcademicAchievement in a Baccalaureate Nursing Program. Journal of Professional Nursing23 (3), 144–149.

Newton, S., Harris, M., Pittilgio, L., Moore, G., 2009. Nursing student math aptitude andsuccess on a medication calculation assessment. Nurse Educator 34 (2), 80–83.

Nibert, A., Young, A., Adamson, C., 2008. Predicting NCLEX success with the HESI exitexam: fourth annual validity study. Computers, Informatics, Nursing 20 (6),261–267.

Norman, I.J., Watson, R., Murrells, T., Calman, L., Redfern, S., 2002. The validity and re-liability of methods to assess the competence to practise of pre-registration nurs-ing and midwifery students. International Journal of Nursing Studies 39 (2),133–145.

Pearson, A., 2004. Balancing the evidence, incorporating the synthesis of qualitativedata into systematic reviews. JBI Reports 2 (2), 45–64.

Pryjmachuk, S., Easton, K., Littlewood, A., 2009. Nurse education: factors associatedwith attrition. Journal of Advanced Nursing 65 (1), 149–160.

Rochford, C., Connolly, M., Drennan, J., 2009. Paid part-time employment and academicperformance of undergraduate nursing students. Nurse Education Today 29 (6),601–606.

Royal College of Nursing United Kingdom, 2005. Past trends, future imperfect? A re-view of the UK nursing labour market 2004 to 2005 Retrieved from http://www.rcn.org.uk/__data/assets/pdf_file/0008/78659/002760.pdf.

Rudel, R.J., 2006. Nontraditional nursing students: the social influences on retention.Teaching and Learning in Nursing 1 (2), 47–54.

Salamonson, Y., Andrew, S., 2006. Academic performance in nursing students: influ-ence of part-time employment, age and ethnicity. Journal of Advanced Nursing55 (3), 342–349.

Salamonson, Y., Everett, B., Koch, J., Andrew, S., Davidson, P.M., 2008. English-languageacculturation predicts academic performance in nursing students who speakEnglish as a second language. Research in Nursing and Health 31 (1), 86–94.

Salamonson, Y., Andrew, S., Everett, B., 2009. Academic engagement and disengage-ment as predictors of performance in pathophysiology among nursing students.Contemporary Nurse 32 (1–2), 123–132.

Sanner, S., Wilson, A., 2008. The experiences of students with English as a second lan-guage in a baccalaureate nursing program. Nurse Education Today 28 (7),807–813.

Sayles, S., Shelton, D., Powell, H., 2003. Predictors of success in nursing education. TheABNF Journal 14 (6), 116–120.

Seldomridge, L.A., DiBartolo, M.C., 2004. Can success and failure be predicted for bacca-laureate graduates on the computerized NCLEX-RN? Journal of Professional Nurs-ing 20 (6), 361–368.

Shelton, E.N., 2003. Faculty support and student retention. Journal of Nursing Educa-tion 42 (2), 68–76.

Shirrell, D., 2008. Critical thinking as a predictor of success in an associate degree nurs-ing program. Teaching and Learning in Nursing 3 (4), 131–136.

Stott, A., 2007. Exploring factors affecting attrition of male students from an under-graduate nursing course: a qualitative study. Nurse Education Today 27 (4),325–332.

Tilley, D.D.S., 2008. Competency in nursing: a concept analysis. Journal of ContinuingEducation in Nursing 39 (2), 58–64.

Tipton, P., Pulliam, M., Beckworth, C., Illich, P., Griffin, R., Tibbitt, A., 2008. Predictors ofassociate degree nursing students' success students. Southern Online Journal ofNursing Research 8 (1) (8 pp.).

Uyehara, J., Magnussen, L., Itano, J., Zhang, S., 2007. Facilitating program and NCLEX-RNsuccess in a generic BSN program. Nursing Forum 42 (1), 31–38.

van Rooyen, P., Dixon, A., Dixon, G., Wells, C., 2006. Entry criteria as predictor of perfor-mance in an undergraduate nursing degree programme. Nurse Education Today 26(7), 593–600.

Vandenhouten, C., 2008. Predictors of success and failure on the NCLEX-RN for Baccalau-reate graduates. Unpublished Ph.D.,MarquetteUniversity, United States—Wisconsin.

Whittemore, R., Knafl, K., 2005. The integrative review: updated methodology. Journalof Advanced Nursing 52 (5), 546–553.

Wood, A.M., Saylor, C., Cohen, J., 2009. Locus of control and academic success amongethnically diverse baccalaureate nursing students. Nursing Education Perspectives30 (5), 290–294.

Yin, T., Burger, C., 2003. Predictors of NCLEX-RN success of associate degree nursinggraduates. Nurse Educator 28 (5), 232–236.


Review: factors influencing nursing students' academic and clinical performance and attrition: an...

Documents

Transcript of Review: factors influencing nursing students' academic and clinical performance and attrition: an...