Re-thinking attrition in student nurses

Journal of Health and Social Care Improvement, February 2011 Issue Re-thinking attrition in student nurses Sophie Orton- Research Assistant, Centre for Health and Social Care Improvement, School of Health and Wellbeing, University of Wolverhampton, Abstract Correspondence: Sophie Orton sophie.orton@wlv.ac.uk Attrition within student nurses is a long-standing and well documented problem within the UK. This review discusses some of the underlying issues that may contribute towards attrition, exploring the concepts of expectation versus experience, stress and career commitment within student nurses. Key words: attrition, student nurses, expectation, stress, career commitment Submitted for Publication- February 2011 Introduction In a large scale review of nurse education conducted by the UKCC (1999), concerns were raised regarding the high attrition rates experienced by pre-registration nursing programs in the UK. Attrition within student nurses is a long-standing problem, having been documented for many decades (Glossop, 2001; Dearey, Watson & Hogston, 2003; Price, 2002). While there is some variation in the recorded rate of attrition, the most recent estimates report an overall rate of 24.79% in the UK, at an estimated cost of 57 million annually (Nursing Standard, 2006). This is an issue that the government is keen to address particularly as there is a considerable financial burden of educating nurses who fail to go on to practice, and the loss of students from pre-registration courses has implications on the general nursing shortage within the NHS (Deary et al., 2003). Additionally, higher education institutions are required to maintain attrition rates below the recommended 13%, and may face financial penalties for failing to achieve this (Deary et al., 2003; Price, 2002). Nursing schools are also concerned about the unnecessary waste of staff time and resources, and the negative impact upon the individual that can be a consequence of student attrition (Pryjmachuk, Easton & Littlewood, 2008). As a result, increasing 1

attention has been paid to identifying reasons for attrition, and what can be done to tackle the problem. Reasons for attrition Research exploring attrition from nursing education has cited a wide range of selfreported reasons given by students who withdraw, ranging from personal reasons (Braithwaite, Elzubeir & Stark, 1994; White, Williams & Green, 1999), family difficulties (Glossop, 2002; White et al., 1999; Lindop, 1987), academic issues (Glossop, 2002; White et al., 1999; Braithwaite et al., 1994; Kevern, Ricketts & Webb, 1999) and financial problems (Glossop 2001; White et al., 1999). Whilst these self reported reasons deserve the attention of researchers, it is likely that a student s decision to withdraw is complex and due to multiple issues. The underlying causes around student nurse discontinuation therefore warrants further consideration. expected. As a result many students find they have ultimately made a mistake in choosing their careers. White et al. (1999) and Glossop (2002) both reported wrong career choice to be among the top five reasons for attrition in their samples. The effect of unmet expectations has been widely examined across professions. In a literature review of organisation, work and person related factors that impact upon staff turnover, Porter and Steers (1973) argued that substantially unmet expectations will increase the likelihood that an individual will resign. However, as each person will have individual expectations of their role, and thus any given variable would not uniformly result in a withdrawal decision (Porter & Steers, 1973). The concept of unmet expectation has great relevance to the topic of student nurse attrition, specifically how expectations of the profession are formed and why they are discordant with actual experiences of nursing. The discrepancy between expectation and experience Misconceptions of nurse education and nursing as a career are commonly cited grounds for attrition. It has been reported that nursing education programmes do not meet expectations for 78% of students (Last & Fulbrook, 2003). Harvey and McMurray (1997) also found that a higher percentage of discontinued student nurses reported the content of their course to differ from what they 2 Research has highlighted that the general public hold perceptions about nursing that are in part influenced by media portrayals of the profession (Harvey & McMurray, 1997). Nurses are portrayed by the media as sex objects (Harvey & McMurray, 1997), less rational, less intelligent and possessing fewer clinical skills than physicians (Kalisch & Kalisch, 1986). A fundamental perception is the idea of nursing being a caring profession. The desire to undertake a caring role is frequently reported

by students as a primary motivation in their career decision (O Brien, Mooney & Glaken, 2008; Mooney, Glaken & O Brien, 2008). This expectation of nursing as a caring profession changes as students gain insight through academic and clinical placement experiences and this can result in a degree of disillusionment for some. First year nursing students expect to be taught practical caring functions of nursing, however their curriculum is actually more directed towards theoretical science subjects; this abstract theoretical care must be incorporated into their perceptions of nursing to cope with the unmet expectation (Granum, 2004). A similar discrepancy occurs during clinical placement. Mackintosh (2006) reported students initially expressed an idealistic image of the caring ethos of nursing. Through exposure to the profession in clinical placements, many students witnessed poor examples of care, cynicism and emotional hardness which were discordant with their previous perceptions. Some students were able to develop appropriate coping strategies to deal with this by internalising the norms of the profession, such as emotional hardening or switching off ; it is likely that those students unable to do this continue to perceive a discrepancy between their expectations and experiences which may provoke withdrawal. Career disillusionment as a whole is a consequence associated with inconsistency between expectations and realities (Corwin, 3 Taves & Haas, 1961). Disillusionment over nurses being under valued, underpaid and over worked prevails among students (Last & Fulbrook, 2003; While & Blackman, 1998), which may be instrumental in many students decisions to withdraw from training. Stress Stress is a commonly cited contributor to student nurse attrition (Lindop, 1987; Deary et al., 2003; Last & Fulbrook, 2003). Recent educational reforms have resulted in students feeling stressed about academic workload, examinations, assignments and the number of classroom hours (Lindop, 1991; Evans & Kelly, 2004; Timmins & Kaliszer, 2002). Clinical placements may also be significant sources of stress (Rhead, 1995). Kleehammer, Hart and Keck (1990) found that the initial clinical placement was the most stressful, and that a fear of making mistakes and clinical procedures were the most anxiety-provoking concerns. Evans and Kelly (2004) further reported that conflict between ideal and real practice on the ward, unfriendly atmospheres and being reprimanded in front staff and patients were the three predominant stressors for students while on placement. Additionally, being given too much responsibility and a lack of supernumerary status can be extremely stressful for students during initial placements (Last and Fulbrook, 2003).

Stress caused by clinical placements is not unique to nursing students.social work students have been found to experience similar anxieties and concerns over their practical placements. Gelman (2004) reported that 84% of their social work student sample reported concerns over a lack of preparedness prior to their placements. A further 74% were concerned about the quality of supervision that they would receive whilst on placement. This illustrates that the potential stress of placements is not restricted to student nurses, and strategies to improve support may be able to be learnt from other disciplines. Whether students develop emotion focused or problem solving focused coping mechanisms in response to stressors is likely to be a more predictive variable in success than the level of stress experienced per se. First year nursing students able to utilise problem focused coping mechanisms have been found to be less distressed than those employing escapist mechanisms such as fantasy or hostility (Jones & Johnston, 1997). However further research suggests that the coping mechanisms employed by students changes throughout their course as their stress levels increase; Deary et al. (2003) found the use of less functional coping mechanisms increased as the students course progressed. Career Commitment The degree to which an individual is committed to the career of nursing may be predictive of their perseverance on the course. A number of definitions for career commitment have been presented within the literature, however that offered by Colarelli and Bishop (1990) of the development of personal career goals, the attachment to, identification with, and involvement in those goals (p.159) is perhaps the most comprehensive in this context. Career commitment was identified by Goulet and Singh (2002) as being influenced by situational variables, individual variables such as job satisfaction and organisational commitment, and extra work variables such as number of dependents. Significant negative correlations have been found between measures of career commitment and job performance and considerations of withdrawal across a wide range of professions (e.g. Carson and Bedeian, 1994; Aryee and Tan, 1992), and more specifically within the nursing workforce (Mrayyan & Al-Faouri, 2008). An individual s commitment to and affiliation with a nursing career is likely to be developed long before they obtain their registered nurse status; students with a high commitment and identification with their career goals are less likely to consider withdrawal. However, using a model of career commitment as a predictive tool has limitations due to the complex interaction between situational, individual and outside variables that comprise the concept of career commitment. 4

Conclusion High attrition rates within pre-registration nursing programmes is an issue that the government is keen to address. Research has identified student s self-reported causal factors that contribute towards the problem, however it is now necessary to move forward and consider student nurse attrition in greater depth and complexity. The discrepancy between expectations and experience, stress and career commitment are all complex issues that may intrinsically influence a student s decision to withdraw from training. Student s discontinuation is likely to be a complex and multi-faceted decision; this should be reflected not only in research into reasons for attrition, but also in strategies to improve retention. References Aryee, S., & Tan, K. (1992). Antecedents and Outcomes of Career Commitment. Journal of Vocational Behavior, 40(3), 288-305. management. Group & Organization Management, 15(2), 158. Corwin, R. G., Taves, M. J., & Haas, J. E. (1961). Professional disillusionment. Nursing Research, 10(3), 141. Deary, I. J., Watson, R., & Hogston, R. (2003). A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing, 43(1), 71-81. Evans, W., & Kelly, B. (2004). Pre-registration diploma student nurse stress and coping measures. Nurse education today, 24(6), 473-482. Gelman, C.R., Anxiety Experienced by Foundation-Year MSW Students Entering Field Placement: Implication for Admissions, Curriculum, and Field Education. Journal of Social Work Education, 2004. 40(1): p. 39-55. Braithwaite, D. N., Elzubeir, M., & Stark, S. (1994). Project 2000 student wastage: a case study. Nurse Educ Today, 14(1), 15-21. Carson, K. D., & Bedeian, A. G. (1994). Career commitment: Construction of a measure and examination of its psychometric properties. Journal of Vocational Behavior, 44(3), 237-262. Colarelli, S. M., & Bishop, R. C. (1990). Career commitment: Functions, correlates, and 5 Glossop, C. (2001). Student nurse attrition from pre-registration courses: investigating methodological issues. Nurse Education Today, 21(3), 170-180. Glossop, C. (2002). Student nurse attrition: use of an exit-interview procedure to determine students' leaving reasons. Nurse Education Today, 22(5), 375-386. Goulet, L. R., & Singh, P. (2002). Career Commitment: A Re-examination and an

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