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Nursing as first choice predicts nursing program completion
Nurse Education Today 34 (2014) 127–131
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Nursing as first choice predicts nursing program completion☆,☆☆ Yenna Salamonson a,⁎, Bronwyn Everett a, 1, Melissa Cooper b, 2, Lien Lombardo c, 3, Roslyn Weaver a, 4, Patricia M. Davidson b, c, 5 a b c
University of Western Sydney, Family and Community Health Research Group (FaCH), School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia University of Technology Sydney, Faculty of Health, PO Box 123, Broadway, NSW 2007, Australia University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia
a r t i c l e
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Article history: Accepted 17 October 2012 Keywords: Career choice Recruitment Retention Nursing students Survey Nursing education
s u m m a r y Background: Attrition from nursing programs is common, costly and burdensome to individuals, nursing faculties and the health care system. Increasingly, nursing faculties are requested to monitor attrition rates as a measure of performance, but little is known of the influence of career choice on program completion. Objectives: The aim of this study was to assess the impact of nursing as a first choice for study on attrition in a baccalaureate nursing program. Design, Setting and Participants: A longitudinal, cohort design was used in this study, which involved undergraduate nursing students enrolled at a university in Australia. Of the 357 participants who completed a baseline survey in 2004 at entry to their Bachelor of Nursing program, 352 were followed up over a six-year period to the end of 2009. Results: Students who selected nursing as their first choice for study were nearly twice as likely (OR: 1.99 95% CI: 1.07–3.68) to complete their nursing program compared to those who did not. These students were also more likely to be older (mean age: 26.8 vs 20.1 years, P b 0.001), and employed in nursing-related work (35% vs 2%, P b 0.001). In addition, the study revealed that male students (OR: 1.93 95% CI: 1.07–3.46) and those who worked more than 16 h per week during semester (OR: 1.80 95% CI: 1.09–2.99) were less likely to complete than their counterparts. Conclusions: These data assist in generating realistic projections of completion and entry to the workforce. Understanding patterns of attrition and individuals' motivations to be a nurse is important not only for supporting nursing students to help them complete their studies but also for developing more targeted strategies directed toward student recruitment and retention. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved.
Introduction The attrition of undergraduate students from nursing programs is a global problem. In the United Kingdom (UK), approximately 25% of nursing students drop out before program completion (Grainger and
☆ Conflict of interest: No conflict of interest has been declared by the authors. ☆☆ Author contributions: YS was responsible for the study conception and design, organized the data collection and performed the data analysis. YS, BE, MC, LL, RW and PMD were responsible for drafting the manuscript. YS, BE, MC, LL, RW and PMD made critical revisions to the paper for important intellectual content. ⁎ Corresponding author. Tel.: +61 2 4620 3322; fax: +61 2 4620 3161. E-mail addresses: [email protected] (Y. Salamonson), [email protected] (B. Everett), [email protected] (M. Cooper), [email protected] (L. Lombardo), [email protected] (R. Weaver), [email protected] (P.M. Davidson). 1 Tel.: +61 2 4620 3770; fax: +61 2 4620 3161. 2 Tel.: +61 2 4620 3322; fax: +61 2 4620 3161. 3 Tel.: +61 2 4620 3406; fax: +61 2 4620 3396. 4 Tel.: +61 2 4620 3157; fax: +61 2 4620 3161. 5 Tel.: +61 2 9514 4822; fax: +61 2 9514 4832.
Bolan, 2006; O'Donnell, 2011), and attrition rates are estimated to range between 20% and 40% in Canada (Grainger and Bolan, 2006), and at least 33% in Australia (Dragon, 2009). The financial cost of nursing student attrition is estimated to be £99 million a year in the UK (Waters, 2008). Added to this financial burden are the personal and institutional costs of attrition, at a time when nursing is facing the challenge of replacing an aging workforce (Graham and Duffield, 2010; Schofield, 2007). Hence, identifying students who are at risk of attrition from nursing programs is of paramount importance to curtail wastage and to limit the shortfall in nursing's future workforce. A number of studies have explored reasons why students leave nursing programs prematurely (Moseley and Mead, 2008; Salamonson et al., 2011; Waters, 2008; Williams, 2010). Although factors such as students' demographics, family and peer support and academic preparation have been shown to be linked with students' academic success and persistence (Mulholland et al., 2008; Urwin et al., 2010), what is perhaps less well known is whether enrolment choices for seeking admission into nursing studies in the first place make a difference in students' persistence and program completion. According to previous research on career choices, wise career
0260-6917/$ – see front matter. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.10.009
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Y. Salamonson et al. / Nurse Education Today 34 (2014) 127–131
decisions are based on a clear understanding of one's abilities, interests, ambitions and limitations, as well as knowledge of the chosen career (Brown et al., 2002). It seems likely that students who select nursing as their first choice because of career aspirations to be a nurse will be more likely to stay and complete their nursing studies. Nevertheless, there is little empirical evidence in the literature to either confirm or refute this association. The process of application for admission into Australian tertiary institutions is centralized, through the Universities Admissions Centre that requires applicants to list their program preferences, and first preference statistics are sometimes used as an indicator of demand for a particular institution (Universities Admissions Centre, 2011). As this information is widely collected and readily available to some tertiary nursing education institutions, knowing whether nursing as a first choice is a predictor of academic success or program completion could assist with more targeted strategies directed toward student recruitment, and, importantly, will help educators identify students who may be at risk of dropping out, so that they can provide additional support for students to stay and complete their nursing studies.
value to indicate the following grades: 0 to 3 for Fail or Unsatisfactory; >3 to 4 for Pass; >4 to 5 for Credit; >5 to 6 for Distinction; and >6 to 7 for High Distinction. The demographic profile of the 352 students who completed the survey and consented to the study was compared with all nursing students enrolled in this BN program in 2004 who were not included in the study sample. The study group did not differ from those who did not participate in the study, in: age (mean: 26.0 years in non-sample versus 25.4 in sample, P = 0.705), gender (85% females versus 83%, P = 0.308), or enrolment classification (9% international students versus 7%, P = 0.283). The Human Research Ethics Committee of the participating university approved the design and conduct of this study. Permission was also sought and received from the nursing faculty and class tutors to invite students to complete the survey after the lecture session. Students were given an information sheet about the study at baseline (first point of data collection), and those who agreed to participate in the study signed a consent form and provided their student identity number to indicate their agreement to be part of this longitudinal study. Data Analysis
The Study Aims This longitudinal study examined the relationship between nursing as the program of first choice on entry into a Bachelor of Nursing (BN) program, and program completion. The study also sought to examine the characteristics of nursing students who selected nursing as their program of first choice and if this profile was related to academic performance and retention. Design This study used a longitudinal, cohort design. The paper is drawn from a larger study that was designed to examine the determinants of attrition and persistence in a Bachelor of Nursing (BN) program. Elsewhere we explored if the reasons for dropping out of a BN program were the same in the first and the second semester of first year (Andrew et al., 2008). In this study, we followed up all first-year students who were surveyed during the first three weeks of semester in 2004, and tracked their enrolment status over a six-year period at three points in time: a) six months following entry into a BN program; b) three years, the standard completion period; and c) six years, the maximum period for program completion. Sample and Data Collection This study was conducted at a university located in a metropolitan region of Australia. In 2004, all commencing first-year nursing students who attended a bioscience lecture during the first three weeks of their BN program were invited to participate in the study. This is an undergraduate program that is usually completed in three years of full-time study, or six years maximum. In addition to asking participants if nursing was their first choice for study, the survey also contained items related to students' sociodemographic characteristics, including engagement in paid employment during semester. As this study was a prospective follow-up of students' academic performance, progression and program attrition, we sought participants' consent to link their completed survey to their academic grades and enrolment status. Of the 357 (49% of all commencing BN students in 2004) who completed the survey at baseline, 352 provided consent for their academic mark and enrolment status to be linked to the survey. Academic grades in this study were measured using participants' cumulative GPA, which was calculated over the duration of the participants' enrolment in the program. The final grade was awarded a numerical
All statistical analyses were performed using SPSS Version 18.0. Distribution of continuous variables (age, hours in paid work during semester and GPA) was checked for normality using the Smirnov– Kolmogorov test. As these variables were not normally distributed, the Mann–Whitney U test was used to assess for group differences between those who did and did not select nursing as their first choice. Continuous variables were also divided into categorical variables for further analysis (hours spent in paid work: not in paid work, 1–16 h per week, more than 16 h per week; GPA: up to 4.0; more than 4.0). Categorical variables were assessed using the Pearson chi-square test. The outcome variable in this study was program attrition at the six-year follow-up, and five student characteristics were used as predictor variables for the multivariate logistic regression analysis. These five characteristics were: non-English-speaking background, age, time spent in paid work, gender, and nursing as first choice. The selection of four of these five variables was informed by previous work that revealed that age (Donaldson et al., 2010), gender (McLaughlin et al., 2010a), language (Salamonson et al., 2011), and time spent in paid work (Andrew et al., 2008) were reported to be linked with attrition of undergraduate nursing students. Age and time spent in paid work were variables dichotomized at the median (age: up to 21 years/more than 21 years; paid work: up to 16 h per week/ more than 16 h per week) before inclusion in the logistic regression. Results are presented as odds ratios with 95% confidence interval (CI). Nagelkerke's R 2 was used to compute for variance explained by the regression model, Cook's distances to identify influential cases, standardized residuals to identify outliers, and Hosmer–Lemeshow test to measure the goodness-of-fit for the logistic regression model. Statistical significance was set at P b 0.05. Results A total of 352 participants were followed-up over a six-year period from the beginning of 2004 to the end of 2009. Baseline characteristics are reported in Table 1. Of the participants surveyed, 83% indicated nursing was their program of first choice upon entry into university. At the end of the first semester, 12% had discontinued the program, at the three-year follow-up the cumulative attrition percentage was 31%, and at the six-year follow-up (maximum period of enrolment) the cumulative attrition percentage was 34%. Those who gained entry into nursing through successful completion of the final year of high school examinations were younger (mean: 21.5, SD: 6.7) compared to students who gained entry through alternate pathways (mean: 29.0, SD: 9.0, P b 0.001). Nevertheless, the
Y. Salamonson et al. / Nurse Education Today 34 (2014) 127–131 Table 1 Characteristics of study sample at baseline (n = 352).
Table 2 Group comparison by nursing as first choice.
Characteristic Age, mean (SD) years (range: 17 to 56) Sex (female)% Marital status (single)% Full-time % International student % Language spoken at home % • English only • Non-English only • Both English and non-English Entry path into nursing program: matriculation performance % Nursing as first choice % Previous nursing experience % Paid work during semester % • Not in paid employment • Nursing or health-related • Non-nursing, non-health-related Hours spent in paid work/week during semester, mean (SD) years (range: 0 to 40) Grade point average after 3 years, mean (SD) (range: 0.4 to 6.4) Discontinued course at the end of the first semester % Discontinued course at the three-year follow-up % Discontinued course at the six-year follow-up %
129
25.7 (8.9) 84 66 84 8 68 11 21 44 83 41 44 29 27 18.0 (9.8) 3.8 (1.3) 12 31 34
latter were more likely to achieve a GPA greater than 4.0 compared to those who gained entry through their matriculation performance (62% versus 38%, P = 0.041). However, there was no significant group difference in the attrition rates at the six-year follow-up and time spent in paid work during semester (P =0.152); the attrition rates were 38% among those not in paid work, 25% among those who spent up to 16 h per week during semester, and 37% among those who spent more than 16 h per week during semester in paid work. Baseline Comparison and After the First Semester by Nursing as First Choice Table 2 shows that older students were significantly more likely to indicate that nursing was their first choice compared to the younger age group (P b 0.001). Similarly, those who were in nursing or health-related employment, and those who were enrolled part-time were more likely to indicate that nursing was their first choice. Table 2 also shows that students who spoke a language other than English at home, and international students who had come to Australia to study, were just as likely to indicate that nursing was the program of first choice. Although the attrition rate after the first semester was higher among those who did not select nursing as their first choice, this group difference was not statistically significant (P = 0.066). Comparison of Enrolment Status and GPA at the Three-year and Six-year Follow-up by Nursing as First Choice At the standard, full-time program completion time of three years, no group differences in enrolment status (P = 0.659) or GPA (P = 0.207) were uncovered between those who selected nursing as their first choice and those who did not (Table 3). However, at the six-year follow-up, which was the maximum time allowed by the university for program completion, students who had selected nursing as their first choice were more likely to have completed the program than those students who had not selected nursing as their first choice (69% versus 54%, P = 0.033). Student Enrolment Characteristics and Program Attrition at Six-year Follow-up Subgroup analyses of local versus international nursing students and full-time versus part-time students and course attrition at the six-year
Characteristic
Nursing not first choice n=59
Nursing first choice n=293
Mann–Whitney U or chi-square test
P value
Age, mean (SD) years Sex (female) % Marital status: single % Full-time % Enrolment type, international student % Language spoken at home % English only Non-English only Both English and non-English Entry path into nursing program: matriculation performance % Paid employment during semester % Not in paid employment Nursing or health-related Other types of paid work Hours spent in paid work during semester, mean (SD) hours/week Previous nursing experience % Attrition from course after first semester %
20.1 (4.7) 80 93 97 5
26.8 (9.1) 85 60 82 7
3805.500 0.898 23.927 7.89 0.250
b0.001a 0.343b b0.001b 0.005b 0.617b
73 9 19
67 11 22
0.829
0.661b
75
37
27.918
b0.001b
49 2 49 13.2 (6.2)
43 35 22 18.9 (10.1)
31.782
b0.001b
1841.000
0.001a
9
48
31.274
b0.001b
19
10
3.371
0.066b
Note: a Mann–Whitney U test. b Pearson χ2 test.
follow-up were undertaken. There were no significant differences between program attrition at the six-year follow-up and type of enrolment (29% part-time versus 35% full-time, P = 0.430) or students' enrolment category (34% local students versus 35% international students, P = 0.903). Predictors of Program Attrition at Six-year Follow-up Using sociodemographic factors and nursing as first choice as predictor variables, logistic regression revealed that male students, students who worked more than 16 h per week during semester, and students who indicated nursing was not their first choice at entry into the program were significantly more likely to have Table 3 Comparison of enrolment status and GPA by nursing as first choice at three-year and six-year follow-up. Characteristic
Enrolment status at the end of the third year % • Attrition from course • Still enrolled, not yet completed • Completed course Grade point average after three years, mean (SD) Grade point average after six years, mean (SD) Enrolment status at the end of the sixth year % • Attrition from course • Completed course Note: a Mann–Whitney U test. b Pearson χ2 test.
Nursing not first choice n=59
Nursing first choice n=293
36 36
30 40
28 3.8 (1.0)
Mann–Whitney U or chi-square test
P value
0.833
0.659b
30 3.9 (1.3)
5865.000
0.207a
3.8 (1.1)
3.9 (1.3)
5904.500
0.232a
46 54
31 69
4.528
0.033b
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Y. Salamonson et al. / Nurse Education Today 34 (2014) 127–131
Table 4 Logistic regression of students' characteristics associated with course attrition at the six-year follow-up. Variable
Coefficient (B)
Standard error (SE)
Adjusted odds ratio (95% CI)
P value
Non-English-speaking background More than 21 years Male Paid work (more than 16 h per week) Nursing, not first choice
0.12
0.25
1.12 (0.69 to 1.84)
0.648
0.06 0.66 0.59
0.24 0.30 0.26
1.06 (0.66 to 1.71) 1.93 (1.07 to 3.46) 1.80 (1.09 to 2.99)
0.815 0.028 0.023
0.69
0.31
1.99 (1.07 to 3.68)
0.029
CI denotes confidence interval. Hosmer–Lemeshow goodness-of-fit for the model, chi-square = 2.70, 7 df (P = 0. 912).
dropped out of the program by the six-year follow-up. Those who did not choose nursing as their first choice were nearly twice as likely to drop out by the maximum enrolment period as those who did select nursing as their first choice (Table 4). No large standardized residuals (less than ± 1.8) or Cook's distances (less than ± 0.08) were uncovered. The logistic model with all five predictor variables included only explained 5.5% of the variance (Nagelkerke's R 2 = 0.055). However, the chi-square value associated with the Hosmer– Lemeshow test was 2.70 (df = 7, n = 350, P = 0.912), indicating a good model fit. Discussion The results of this study show that those students who selected nursing as their first choice at entry into the program were more likely to complete the nursing program. This supports previous research advocating the active engagement in choosing one's vocation, instead of just allowing chance to operate (Brown et al., 2002). In contrast to previous studies that explored why students choose nursing, and how motivational factors lead to career intent in nursing among prospective students (Cho et al., 2010; Lai et al., 2008), this study provides a link between career intent in nursing and program completion. In addition to this finding, two other variables – male gender and working more than 16 h per week during semester – were also important predictors of attrition before program completion, which is consistent with previous reports on the relationship between males and program withdrawals (McLaughlin et al., 2010b), and the negative impact of hours spent in paid employment on program completion (Polidano and Zakirova, 2011). Unlike the study by Lai et al. (2008) on career intent of nursing students, which reported that nursing was not the first preference for more than half of those surveyed, the current study found that the majority (83%) of students indicated that nursing was their program of first choice. Further, the study also revealed that the characteristics of students for whom nursing was their first choice were different from their counterparts as those who selected nursing as first choice were older, and were also engaging in nursing-related employment. This could be a reflection of the entry of older nursing students who have begun their careers in other fields, a trend that has previously been reported (Auerbach et al., 2007), as well as those who were already in nursing-related work who decided to undertake further nursing studies as a career choice. In contrast, younger students being less likely to select nursing as their first choice may reflect ambivalence and less certainty about nursing as a career choice (Ferguson and Hope, 1999). The finding that 12% of nursing students had discontinued their program by the end of their first semester is consistent with attrition figures reported in similar studies which examined nursing student attrition during the first year (Andrew et al., 2008; Gaynor et al., 2006). Interestingly, a trend was already emerging at the end of the first semester in relation to nursing students who discontinued their
program, with nearly twice as many students who did not select nursing as their first choice dropping out, compared to those who did have nursing as their first choice. A qualitative study which explored reasons for nursing student attrition in a BN program found that for those students who discontinued in the first semester, nursing was often not their first choice (Andrew et al., 2008). In contrast, those students who dropped out later in their nursing studies discontinued because of difficulties experienced combining work and study, the reality of clinical experience and having to juggle a number of roles and responsibilities (Andrew et al., 2008). While the attrition rates of 31% (three years) and the overall program attrition of 34% (six years) in this study support previously reported findings of attrition rates ranging from 20% to 40% (Dragon, 2009; Gaynor et al., 2006; Grainger and Bolan, 2006; O'Donnell, 2011), this study also revealed an even higher attrition rate of 46% in those students who did not select nursing as their first choice. This study has several limitations. The sociodemographic profile of the local population may have influenced participant characteristics and therefore the capacity to extrapolate these findings to other populations. Nevertheless, students enrolled at this university are likely to be typical of other Australian undergraduate nursing students. Hence, the findings of this study are likely to be generalizable to other nursing education institutions within the Australian higher education setting. Given the differences in international baccalaureate nursing programs including the length of program and bursary support, these findings may not be applicable in other international settings. Further, only one item was used to establish if nursing was their first choice and no other related or supporting information was collected to uncover the degree of students' motivation, as it is known that some students are willing to pursue their goal of career aspiration more earnestly than others (Spouse, 2000). Finally, the current study did not address the reasons for attrition, if students left the program due to a loss of interest in nursing as a career, or due to failure to meet coursework requirements in their nursing studies. In spite of these limitations, this study is one of only a few that has addressed attrition in the context of program choices and the implications for curriculum design and student support. It also challenges the fiscal considerations of educational administration. These data provide some useful directions for planning and structuring BN programs. Although a degree of attrition is inevitable, implementing proactive strategies to both increase the appeal of nursing as a career option and to decrease the impact of leaving a BN program once enrolled will assist with workforce predictions and faculty performance, as well as help to reduce the personal cost to students. Strategies to promote nursing as a career choice for male students have been previously described and include targeting school guidance counselors to increase their awareness of the options for male nurses (Gilchrist and Rector, 2007), depicting men as well as women in recruitment materials (Meadus and Twomey, 2011), and supporting and educating family members that men have a valid and much needed role in nursing (Wilson, 2005). Stott (2004) suggests that the increased risk for male students dropping out of their nursing program could be reduced by implementing activities that unite nursing students, such as providing support or mentoring groups, and encouraging greater visibility of male nursing students to promote retention of this group of students. In addition, faculty need to be aware of possible sexism and bias in both course curricula and clinical placements, and be more proactive in promoting a learning environment that takes account of the learning and communication styles of male students (Meadus and Twomey, 2011). Finally, strategies for increasing the appeal of nursing could be implemented while students are still considering their career options, for example during secondary school. This could include the use of male and female Registered Nurses from a range of nursing specialties who could inspire and motivate prospective students by sharing their
Y. Salamonson et al. / Nurse Education Today 34 (2014) 127–131
personal experience. This strategy could also be useful for those students who are already undertaking nursing studies, but did not select nursing as their first choice. The personal experiences of nurses and the diverse range of practice settings in which they work may reveal opportunities not previously considered, thus motivating these students to persevere with their studies, and affirming the decision of those students who did select nursing as their first choice. Conclusion Increasingly, nursing schools are under pressure to monitor attrition. Attrition is costly to students, schools and more broadly the health care system, which is dependent on accurate workforce predictions. Obtaining an understanding of patterns and predictors of attrition is critical for targeting those at highest risk and addressing their need for support and assistance. References Andrew, S., Salamonson, Y., Weaver, R., Smith, A., O'Reilly, R., Taylor, C., 2008. Hate the course or hate to go: semester differences in first year nursing attrition. Nurse Education Today 28 (7), 865–872. Auerbach, D.I., Buerhaus, P.I., Staiger, D.O., 2007. Better late than never: workforce supply implications of later entry into nursing. Health Affairs 26 (1), 178–185. Brown, D., Brown, S.D., Collin, A., Dawis, R.V., Gottfredson, L.S., Hackett, G., et al., 2002. Career Choice and Development, 4th ed. Jossey-Bass, San Francisco. Cho, S.-H., Jung, S.Y., Jang, S., 2010. Who enters nursing schools and why do they choose nursing? A comparison with female non-nursing students using longitudinal data. Nurse Education Today 30 (2), 180–186. Donaldson, J.H., McCallum, J., Lafferty, P., 2010. Can we predict successful completion of the common foundation programme at interview? Nurse Education Today 30 (7), 649–656. Dragon, N., 2009. Nurse education: our students, our future. Australian Nursing Journal 16 (7), 22–25. Ferguson, K., Hope, K., 1999. From novice to competent practitioner: tracking the progress of undergraduate mental health nursing students. Journal of Advanced Nursing 29 (3), 630–638. Gaynor, L., Gallasch, T., Yorkston, E., Stewart, S., Turner, C., 2006. Where do all the undergraduate and new graduate nurses go and why? A search for empirical research evidence. Australian Journal of Advanced Nursing 24 (2), 26–32. Gilchrist, K.L., Rector, C., 2007. Can you keep them? Strategies to attract and retain nursing students from diverse populations: best practices in nursing education. Journal of Transcultural Nursing 18 (3), 277–285.
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Graham, E.M., Duffield, C., 2010. An ageing nursing workforce. Australian Health Review 34 (1), 44–48. Grainger, P., Bolan, C., 2006. Perceptions of nursing as a career choice of students in the baccalaureate nursing program. Nurse Education Today 26 (1), 38–44. Lai, H.L., Lin, Y.P., Chang, H.K., Chen, C.J., Peng, T.C., Chang, F.M., 2008. Is nursing profession my first choice? A follow up survey in pre-registeration student nurses. Nurse Education Today 28 (6), 768–776. McLaughlin, K., Moutray, M., Moore, C., 2010a. Career motivation in nursing students and the perceived influence of significant others. Journal of Advanced Nursing 66 (2), 404–412. McLaughlin, K., Muldoon, O.T., Moutray, M., 2010b. Gender, gender roles and completion of nursing education: a longitudinal study. Nurse Education Today 30 (4), 303–307. Meadus, R.J., Twomey, J.C., 2011. Men student nurses: the nursing education experience. Nursing Forum 46 (4), 269–279. Moseley, L.G., Mead, D.M., 2008. Predicting who will drop out of nursing courses: a machine earning exercise. Nurse Education Today 28 (4), 469–475. Mulholland, J., Anionwu, E.N., Atkins, R., Tappern, M., Franks, P.J., 2008. Diversity, attrition and transition into nursing. Journal of Advanced Nursing 64 (1), 49–59. O'Donnell, H., 2011. Expectations and voluntary attrition in nursing students. Nurse Education in Practice 11 (1), 54–63. Polidano, C., Zakirova, R., 2011. Outcomes from combining work and tertiary study. (Retrieved 20 January, 2011, from) http://www.ncver.edu.au/publications/2320.html. Salamonson, Y., Andrew, S., Clauson, J., Jacobs, S., Cleary, M., Jackson, D., 2011. Linguistic diversity as sociodemographic predictor of nursing program progression and completion. Contemporary Nurse 38 (1–2), 84–93. Schofield, D.J., 2007. Replacing the projected retiring baby boomer nursing cohort 2001–2026. BMC Health Services Research 7. Spouse, J., 2000. An impossible dream? Images of nursing held by pre-registration students and their effect on sustaining motivation to become nurses. Journal of Advanced Nursing 32 (3), 730–739. Stott, A., 2004. Issues in the socialisation process of the male student nurse: implications for retention in undergraduate nursing courses. Nurse Education Today 24 (2), 91–97. Universities Admissions Centre, 2011. University preference statistics for 2012 admissions. (Retrieved December 26, 2011, from) http://www.uac.edu.au/documents/ media-releases/undergraduate/preference-stats_2011.pdf. Urwin, S., Stanley, R., Jones, M., Gallagher, A., Wainwright, P., Perkins, A., 2010. Understanding student nurse attrition: learning from the literature. Nurse Education Today 30 (2), 202–207. Waters, A., 2008. Nursing student attrition is costing taxpayers pounds 99 million a year. Nursing Standard 22 (31), 12–15. Williams, M.G., 2010. Attrition and retention in the nursing major: understanding persistence in beginning nursing students. Nursing Education Perspectives 31 (6), 362–367. Wilson, G., 2005. The experience of males entering nursing: a phenomenological analysis of professionally enhancing factors and barriers. Contemporary Nurse 20 (2), 221–233.
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Nursing as first choice predicts nursing program completion☆,☆☆ Yenna Salamonson a,⁎, Bronwyn Everett a, 1, Melissa Cooper b, 2, Lien Lombardo c, 3, Roslyn Weaver a, 4, Patricia M. Davidson b, c, 5 a b c
University of Western Sydney, Family and Community Health Research Group (FaCH), School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia University of Technology Sydney, Faculty of Health, PO Box 123, Broadway, NSW 2007, Australia University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia
a r t i c l e
i n f o
Article history: Accepted 17 October 2012 Keywords: Career choice Recruitment Retention Nursing students Survey Nursing education
s u m m a r y Background: Attrition from nursing programs is common, costly and burdensome to individuals, nursing faculties and the health care system. Increasingly, nursing faculties are requested to monitor attrition rates as a measure of performance, but little is known of the influence of career choice on program completion. Objectives: The aim of this study was to assess the impact of nursing as a first choice for study on attrition in a baccalaureate nursing program. Design, Setting and Participants: A longitudinal, cohort design was used in this study, which involved undergraduate nursing students enrolled at a university in Australia. Of the 357 participants who completed a baseline survey in 2004 at entry to their Bachelor of Nursing program, 352 were followed up over a six-year period to the end of 2009. Results: Students who selected nursing as their first choice for study were nearly twice as likely (OR: 1.99 95% CI: 1.07–3.68) to complete their nursing program compared to those who did not. These students were also more likely to be older (mean age: 26.8 vs 20.1 years, P b 0.001), and employed in nursing-related work (35% vs 2%, P b 0.001). In addition, the study revealed that male students (OR: 1.93 95% CI: 1.07–3.46) and those who worked more than 16 h per week during semester (OR: 1.80 95% CI: 1.09–2.99) were less likely to complete than their counterparts. Conclusions: These data assist in generating realistic projections of completion and entry to the workforce. Understanding patterns of attrition and individuals' motivations to be a nurse is important not only for supporting nursing students to help them complete their studies but also for developing more targeted strategies directed toward student recruitment and retention. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved.
Introduction The attrition of undergraduate students from nursing programs is a global problem. In the United Kingdom (UK), approximately 25% of nursing students drop out before program completion (Grainger and
☆ Conflict of interest: No conflict of interest has been declared by the authors. ☆☆ Author contributions: YS was responsible for the study conception and design, organized the data collection and performed the data analysis. YS, BE, MC, LL, RW and PMD were responsible for drafting the manuscript. YS, BE, MC, LL, RW and PMD made critical revisions to the paper for important intellectual content. ⁎ Corresponding author. Tel.: +61 2 4620 3322; fax: +61 2 4620 3161. E-mail addresses: [email protected] (Y. Salamonson), [email protected] (B. Everett), [email protected] (M. Cooper), [email protected] (L. Lombardo), [email protected] (R. Weaver), [email protected] (P.M. Davidson). 1 Tel.: +61 2 4620 3770; fax: +61 2 4620 3161. 2 Tel.: +61 2 4620 3322; fax: +61 2 4620 3161. 3 Tel.: +61 2 4620 3406; fax: +61 2 4620 3396. 4 Tel.: +61 2 4620 3157; fax: +61 2 4620 3161. 5 Tel.: +61 2 9514 4822; fax: +61 2 9514 4832.
Bolan, 2006; O'Donnell, 2011), and attrition rates are estimated to range between 20% and 40% in Canada (Grainger and Bolan, 2006), and at least 33% in Australia (Dragon, 2009). The financial cost of nursing student attrition is estimated to be £99 million a year in the UK (Waters, 2008). Added to this financial burden are the personal and institutional costs of attrition, at a time when nursing is facing the challenge of replacing an aging workforce (Graham and Duffield, 2010; Schofield, 2007). Hence, identifying students who are at risk of attrition from nursing programs is of paramount importance to curtail wastage and to limit the shortfall in nursing's future workforce. A number of studies have explored reasons why students leave nursing programs prematurely (Moseley and Mead, 2008; Salamonson et al., 2011; Waters, 2008; Williams, 2010). Although factors such as students' demographics, family and peer support and academic preparation have been shown to be linked with students' academic success and persistence (Mulholland et al., 2008; Urwin et al., 2010), what is perhaps less well known is whether enrolment choices for seeking admission into nursing studies in the first place make a difference in students' persistence and program completion. According to previous research on career choices, wise career
0260-6917/$ – see front matter. Crown Copyright © 2012 Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2012.10.009
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decisions are based on a clear understanding of one's abilities, interests, ambitions and limitations, as well as knowledge of the chosen career (Brown et al., 2002). It seems likely that students who select nursing as their first choice because of career aspirations to be a nurse will be more likely to stay and complete their nursing studies. Nevertheless, there is little empirical evidence in the literature to either confirm or refute this association. The process of application for admission into Australian tertiary institutions is centralized, through the Universities Admissions Centre that requires applicants to list their program preferences, and first preference statistics are sometimes used as an indicator of demand for a particular institution (Universities Admissions Centre, 2011). As this information is widely collected and readily available to some tertiary nursing education institutions, knowing whether nursing as a first choice is a predictor of academic success or program completion could assist with more targeted strategies directed toward student recruitment, and, importantly, will help educators identify students who may be at risk of dropping out, so that they can provide additional support for students to stay and complete their nursing studies.
value to indicate the following grades: 0 to 3 for Fail or Unsatisfactory; >3 to 4 for Pass; >4 to 5 for Credit; >5 to 6 for Distinction; and >6 to 7 for High Distinction. The demographic profile of the 352 students who completed the survey and consented to the study was compared with all nursing students enrolled in this BN program in 2004 who were not included in the study sample. The study group did not differ from those who did not participate in the study, in: age (mean: 26.0 years in non-sample versus 25.4 in sample, P = 0.705), gender (85% females versus 83%, P = 0.308), or enrolment classification (9% international students versus 7%, P = 0.283). The Human Research Ethics Committee of the participating university approved the design and conduct of this study. Permission was also sought and received from the nursing faculty and class tutors to invite students to complete the survey after the lecture session. Students were given an information sheet about the study at baseline (first point of data collection), and those who agreed to participate in the study signed a consent form and provided their student identity number to indicate their agreement to be part of this longitudinal study. Data Analysis
The Study Aims This longitudinal study examined the relationship between nursing as the program of first choice on entry into a Bachelor of Nursing (BN) program, and program completion. The study also sought to examine the characteristics of nursing students who selected nursing as their program of first choice and if this profile was related to academic performance and retention. Design This study used a longitudinal, cohort design. The paper is drawn from a larger study that was designed to examine the determinants of attrition and persistence in a Bachelor of Nursing (BN) program. Elsewhere we explored if the reasons for dropping out of a BN program were the same in the first and the second semester of first year (Andrew et al., 2008). In this study, we followed up all first-year students who were surveyed during the first three weeks of semester in 2004, and tracked their enrolment status over a six-year period at three points in time: a) six months following entry into a BN program; b) three years, the standard completion period; and c) six years, the maximum period for program completion. Sample and Data Collection This study was conducted at a university located in a metropolitan region of Australia. In 2004, all commencing first-year nursing students who attended a bioscience lecture during the first three weeks of their BN program were invited to participate in the study. This is an undergraduate program that is usually completed in three years of full-time study, or six years maximum. In addition to asking participants if nursing was their first choice for study, the survey also contained items related to students' sociodemographic characteristics, including engagement in paid employment during semester. As this study was a prospective follow-up of students' academic performance, progression and program attrition, we sought participants' consent to link their completed survey to their academic grades and enrolment status. Of the 357 (49% of all commencing BN students in 2004) who completed the survey at baseline, 352 provided consent for their academic mark and enrolment status to be linked to the survey. Academic grades in this study were measured using participants' cumulative GPA, which was calculated over the duration of the participants' enrolment in the program. The final grade was awarded a numerical
All statistical analyses were performed using SPSS Version 18.0. Distribution of continuous variables (age, hours in paid work during semester and GPA) was checked for normality using the Smirnov– Kolmogorov test. As these variables were not normally distributed, the Mann–Whitney U test was used to assess for group differences between those who did and did not select nursing as their first choice. Continuous variables were also divided into categorical variables for further analysis (hours spent in paid work: not in paid work, 1–16 h per week, more than 16 h per week; GPA: up to 4.0; more than 4.0). Categorical variables were assessed using the Pearson chi-square test. The outcome variable in this study was program attrition at the six-year follow-up, and five student characteristics were used as predictor variables for the multivariate logistic regression analysis. These five characteristics were: non-English-speaking background, age, time spent in paid work, gender, and nursing as first choice. The selection of four of these five variables was informed by previous work that revealed that age (Donaldson et al., 2010), gender (McLaughlin et al., 2010a), language (Salamonson et al., 2011), and time spent in paid work (Andrew et al., 2008) were reported to be linked with attrition of undergraduate nursing students. Age and time spent in paid work were variables dichotomized at the median (age: up to 21 years/more than 21 years; paid work: up to 16 h per week/ more than 16 h per week) before inclusion in the logistic regression. Results are presented as odds ratios with 95% confidence interval (CI). Nagelkerke's R 2 was used to compute for variance explained by the regression model, Cook's distances to identify influential cases, standardized residuals to identify outliers, and Hosmer–Lemeshow test to measure the goodness-of-fit for the logistic regression model. Statistical significance was set at P b 0.05. Results A total of 352 participants were followed-up over a six-year period from the beginning of 2004 to the end of 2009. Baseline characteristics are reported in Table 1. Of the participants surveyed, 83% indicated nursing was their program of first choice upon entry into university. At the end of the first semester, 12% had discontinued the program, at the three-year follow-up the cumulative attrition percentage was 31%, and at the six-year follow-up (maximum period of enrolment) the cumulative attrition percentage was 34%. Those who gained entry into nursing through successful completion of the final year of high school examinations were younger (mean: 21.5, SD: 6.7) compared to students who gained entry through alternate pathways (mean: 29.0, SD: 9.0, P b 0.001). Nevertheless, the
Y. Salamonson et al. / Nurse Education Today 34 (2014) 127–131 Table 1 Characteristics of study sample at baseline (n = 352).
Table 2 Group comparison by nursing as first choice.
Characteristic Age, mean (SD) years (range: 17 to 56) Sex (female)% Marital status (single)% Full-time % International student % Language spoken at home % • English only • Non-English only • Both English and non-English Entry path into nursing program: matriculation performance % Nursing as first choice % Previous nursing experience % Paid work during semester % • Not in paid employment • Nursing or health-related • Non-nursing, non-health-related Hours spent in paid work/week during semester, mean (SD) years (range: 0 to 40) Grade point average after 3 years, mean (SD) (range: 0.4 to 6.4) Discontinued course at the end of the first semester % Discontinued course at the three-year follow-up % Discontinued course at the six-year follow-up %
129
25.7 (8.9) 84 66 84 8 68 11 21 44 83 41 44 29 27 18.0 (9.8) 3.8 (1.3) 12 31 34
latter were more likely to achieve a GPA greater than 4.0 compared to those who gained entry through their matriculation performance (62% versus 38%, P = 0.041). However, there was no significant group difference in the attrition rates at the six-year follow-up and time spent in paid work during semester (P =0.152); the attrition rates were 38% among those not in paid work, 25% among those who spent up to 16 h per week during semester, and 37% among those who spent more than 16 h per week during semester in paid work. Baseline Comparison and After the First Semester by Nursing as First Choice Table 2 shows that older students were significantly more likely to indicate that nursing was their first choice compared to the younger age group (P b 0.001). Similarly, those who were in nursing or health-related employment, and those who were enrolled part-time were more likely to indicate that nursing was their first choice. Table 2 also shows that students who spoke a language other than English at home, and international students who had come to Australia to study, were just as likely to indicate that nursing was the program of first choice. Although the attrition rate after the first semester was higher among those who did not select nursing as their first choice, this group difference was not statistically significant (P = 0.066). Comparison of Enrolment Status and GPA at the Three-year and Six-year Follow-up by Nursing as First Choice At the standard, full-time program completion time of three years, no group differences in enrolment status (P = 0.659) or GPA (P = 0.207) were uncovered between those who selected nursing as their first choice and those who did not (Table 3). However, at the six-year follow-up, which was the maximum time allowed by the university for program completion, students who had selected nursing as their first choice were more likely to have completed the program than those students who had not selected nursing as their first choice (69% versus 54%, P = 0.033). Student Enrolment Characteristics and Program Attrition at Six-year Follow-up Subgroup analyses of local versus international nursing students and full-time versus part-time students and course attrition at the six-year
Characteristic
Nursing not first choice n=59
Nursing first choice n=293
Mann–Whitney U or chi-square test
P value
Age, mean (SD) years Sex (female) % Marital status: single % Full-time % Enrolment type, international student % Language spoken at home % English only Non-English only Both English and non-English Entry path into nursing program: matriculation performance % Paid employment during semester % Not in paid employment Nursing or health-related Other types of paid work Hours spent in paid work during semester, mean (SD) hours/week Previous nursing experience % Attrition from course after first semester %
20.1 (4.7) 80 93 97 5
26.8 (9.1) 85 60 82 7
3805.500 0.898 23.927 7.89 0.250
b0.001a 0.343b b0.001b 0.005b 0.617b
73 9 19
67 11 22
0.829
0.661b
75
37
27.918
b0.001b
49 2 49 13.2 (6.2)
43 35 22 18.9 (10.1)
31.782
b0.001b
1841.000
0.001a
9
48
31.274
b0.001b
19
10
3.371
0.066b
Note: a Mann–Whitney U test. b Pearson χ2 test.
follow-up were undertaken. There were no significant differences between program attrition at the six-year follow-up and type of enrolment (29% part-time versus 35% full-time, P = 0.430) or students' enrolment category (34% local students versus 35% international students, P = 0.903). Predictors of Program Attrition at Six-year Follow-up Using sociodemographic factors and nursing as first choice as predictor variables, logistic regression revealed that male students, students who worked more than 16 h per week during semester, and students who indicated nursing was not their first choice at entry into the program were significantly more likely to have Table 3 Comparison of enrolment status and GPA by nursing as first choice at three-year and six-year follow-up. Characteristic
Enrolment status at the end of the third year % • Attrition from course • Still enrolled, not yet completed • Completed course Grade point average after three years, mean (SD) Grade point average after six years, mean (SD) Enrolment status at the end of the sixth year % • Attrition from course • Completed course Note: a Mann–Whitney U test. b Pearson χ2 test.
Nursing not first choice n=59
Nursing first choice n=293
36 36
30 40
28 3.8 (1.0)
Mann–Whitney U or chi-square test
P value
0.833
0.659b
30 3.9 (1.3)
5865.000
0.207a
3.8 (1.1)
3.9 (1.3)
5904.500
0.232a
46 54
31 69
4.528
0.033b
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Table 4 Logistic regression of students' characteristics associated with course attrition at the six-year follow-up. Variable
Coefficient (B)
Standard error (SE)
Adjusted odds ratio (95% CI)
P value
Non-English-speaking background More than 21 years Male Paid work (more than 16 h per week) Nursing, not first choice
0.12
0.25
1.12 (0.69 to 1.84)
0.648
0.06 0.66 0.59
0.24 0.30 0.26
1.06 (0.66 to 1.71) 1.93 (1.07 to 3.46) 1.80 (1.09 to 2.99)
0.815 0.028 0.023
0.69
0.31
1.99 (1.07 to 3.68)
0.029
CI denotes confidence interval. Hosmer–Lemeshow goodness-of-fit for the model, chi-square = 2.70, 7 df (P = 0. 912).
dropped out of the program by the six-year follow-up. Those who did not choose nursing as their first choice were nearly twice as likely to drop out by the maximum enrolment period as those who did select nursing as their first choice (Table 4). No large standardized residuals (less than ± 1.8) or Cook's distances (less than ± 0.08) were uncovered. The logistic model with all five predictor variables included only explained 5.5% of the variance (Nagelkerke's R 2 = 0.055). However, the chi-square value associated with the Hosmer– Lemeshow test was 2.70 (df = 7, n = 350, P = 0.912), indicating a good model fit. Discussion The results of this study show that those students who selected nursing as their first choice at entry into the program were more likely to complete the nursing program. This supports previous research advocating the active engagement in choosing one's vocation, instead of just allowing chance to operate (Brown et al., 2002). In contrast to previous studies that explored why students choose nursing, and how motivational factors lead to career intent in nursing among prospective students (Cho et al., 2010; Lai et al., 2008), this study provides a link between career intent in nursing and program completion. In addition to this finding, two other variables – male gender and working more than 16 h per week during semester – were also important predictors of attrition before program completion, which is consistent with previous reports on the relationship between males and program withdrawals (McLaughlin et al., 2010b), and the negative impact of hours spent in paid employment on program completion (Polidano and Zakirova, 2011). Unlike the study by Lai et al. (2008) on career intent of nursing students, which reported that nursing was not the first preference for more than half of those surveyed, the current study found that the majority (83%) of students indicated that nursing was their program of first choice. Further, the study also revealed that the characteristics of students for whom nursing was their first choice were different from their counterparts as those who selected nursing as first choice were older, and were also engaging in nursing-related employment. This could be a reflection of the entry of older nursing students who have begun their careers in other fields, a trend that has previously been reported (Auerbach et al., 2007), as well as those who were already in nursing-related work who decided to undertake further nursing studies as a career choice. In contrast, younger students being less likely to select nursing as their first choice may reflect ambivalence and less certainty about nursing as a career choice (Ferguson and Hope, 1999). The finding that 12% of nursing students had discontinued their program by the end of their first semester is consistent with attrition figures reported in similar studies which examined nursing student attrition during the first year (Andrew et al., 2008; Gaynor et al., 2006). Interestingly, a trend was already emerging at the end of the first semester in relation to nursing students who discontinued their
program, with nearly twice as many students who did not select nursing as their first choice dropping out, compared to those who did have nursing as their first choice. A qualitative study which explored reasons for nursing student attrition in a BN program found that for those students who discontinued in the first semester, nursing was often not their first choice (Andrew et al., 2008). In contrast, those students who dropped out later in their nursing studies discontinued because of difficulties experienced combining work and study, the reality of clinical experience and having to juggle a number of roles and responsibilities (Andrew et al., 2008). While the attrition rates of 31% (three years) and the overall program attrition of 34% (six years) in this study support previously reported findings of attrition rates ranging from 20% to 40% (Dragon, 2009; Gaynor et al., 2006; Grainger and Bolan, 2006; O'Donnell, 2011), this study also revealed an even higher attrition rate of 46% in those students who did not select nursing as their first choice. This study has several limitations. The sociodemographic profile of the local population may have influenced participant characteristics and therefore the capacity to extrapolate these findings to other populations. Nevertheless, students enrolled at this university are likely to be typical of other Australian undergraduate nursing students. Hence, the findings of this study are likely to be generalizable to other nursing education institutions within the Australian higher education setting. Given the differences in international baccalaureate nursing programs including the length of program and bursary support, these findings may not be applicable in other international settings. Further, only one item was used to establish if nursing was their first choice and no other related or supporting information was collected to uncover the degree of students' motivation, as it is known that some students are willing to pursue their goal of career aspiration more earnestly than others (Spouse, 2000). Finally, the current study did not address the reasons for attrition, if students left the program due to a loss of interest in nursing as a career, or due to failure to meet coursework requirements in their nursing studies. In spite of these limitations, this study is one of only a few that has addressed attrition in the context of program choices and the implications for curriculum design and student support. It also challenges the fiscal considerations of educational administration. These data provide some useful directions for planning and structuring BN programs. Although a degree of attrition is inevitable, implementing proactive strategies to both increase the appeal of nursing as a career option and to decrease the impact of leaving a BN program once enrolled will assist with workforce predictions and faculty performance, as well as help to reduce the personal cost to students. Strategies to promote nursing as a career choice for male students have been previously described and include targeting school guidance counselors to increase their awareness of the options for male nurses (Gilchrist and Rector, 2007), depicting men as well as women in recruitment materials (Meadus and Twomey, 2011), and supporting and educating family members that men have a valid and much needed role in nursing (Wilson, 2005). Stott (2004) suggests that the increased risk for male students dropping out of their nursing program could be reduced by implementing activities that unite nursing students, such as providing support or mentoring groups, and encouraging greater visibility of male nursing students to promote retention of this group of students. In addition, faculty need to be aware of possible sexism and bias in both course curricula and clinical placements, and be more proactive in promoting a learning environment that takes account of the learning and communication styles of male students (Meadus and Twomey, 2011). Finally, strategies for increasing the appeal of nursing could be implemented while students are still considering their career options, for example during secondary school. This could include the use of male and female Registered Nurses from a range of nursing specialties who could inspire and motivate prospective students by sharing their
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personal experience. This strategy could also be useful for those students who are already undertaking nursing studies, but did not select nursing as their first choice. The personal experiences of nurses and the diverse range of practice settings in which they work may reveal opportunities not previously considered, thus motivating these students to persevere with their studies, and affirming the decision of those students who did select nursing as their first choice. Conclusion Increasingly, nursing schools are under pressure to monitor attrition. Attrition is costly to students, schools and more broadly the health care system, which is dependent on accurate workforce predictions. Obtaining an understanding of patterns and predictors of attrition is critical for targeting those at highest risk and addressing their need for support and assistance. References Andrew, S., Salamonson, Y., Weaver, R., Smith, A., O'Reilly, R., Taylor, C., 2008. Hate the course or hate to go: semester differences in first year nursing attrition. Nurse Education Today 28 (7), 865–872. Auerbach, D.I., Buerhaus, P.I., Staiger, D.O., 2007. Better late than never: workforce supply implications of later entry into nursing. Health Affairs 26 (1), 178–185. Brown, D., Brown, S.D., Collin, A., Dawis, R.V., Gottfredson, L.S., Hackett, G., et al., 2002. Career Choice and Development, 4th ed. Jossey-Bass, San Francisco. Cho, S.-H., Jung, S.Y., Jang, S., 2010. Who enters nursing schools and why do they choose nursing? A comparison with female non-nursing students using longitudinal data. Nurse Education Today 30 (2), 180–186. Donaldson, J.H., McCallum, J., Lafferty, P., 2010. Can we predict successful completion of the common foundation programme at interview? Nurse Education Today 30 (7), 649–656. Dragon, N., 2009. Nurse education: our students, our future. Australian Nursing Journal 16 (7), 22–25. Ferguson, K., Hope, K., 1999. From novice to competent practitioner: tracking the progress of undergraduate mental health nursing students. Journal of Advanced Nursing 29 (3), 630–638. Gaynor, L., Gallasch, T., Yorkston, E., Stewart, S., Turner, C., 2006. Where do all the undergraduate and new graduate nurses go and why? A search for empirical research evidence. Australian Journal of Advanced Nursing 24 (2), 26–32. Gilchrist, K.L., Rector, C., 2007. Can you keep them? Strategies to attract and retain nursing students from diverse populations: best practices in nursing education. Journal of Transcultural Nursing 18 (3), 277–285.
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