- Email: [email protected]
Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach
Nurse Education in Practice xxx (2016) 1e6
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach Yenna Salamonson a, *, 1, Lucie M. Ramjan a, 1, Simon van den Nieuwenhuizen a, Lauren Metcalfe a, 1, Sungwon Chang b, Bronwyn Everett a, c, 1 a
University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia University of Western Sydney, School of Nursing and Midwifery & Postdoctoral Research Fellow, University of Technology Sydney, Faculty of Health, Level 7, Building 10, City Campus, PO Box 123, Broadway, NSW 2007, Australia c University of Western Sydney, South Western Sydney Local Health District (SWSLHD), Locked Bag 7103, Liverpool BC, NSW 1871, Australia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 September 2014 Received in revised form 8 August 2015 Accepted 4 January 2016
This paper examines the relationship between nursing students' sense of coherence, self-regulated learning and academic performance in bioscience. While there is increasing recognition of a need to foster students' self-regulated learning, little is known about the relationship of psychological strengths, particularly sense of coherence and academic performance. Using a prospective, correlational design, 563 first year nursing students completed the three dimensions of sense of coherence scale e comprehensibility, manageability and meaningfulness, and five components of self-regulated learning strategy e elaboration, organisation, rehearsal, self-efficacy and task value. Cluster analysis was used to group respondents into three clusters, based on their sense of coherence subscale scores. Although there were no sociodemographic differences in sense of coherence subscale scores, those with higher sense of coherence were more likely to adopt self-regulated learning strategies. Furthermore, academic grades collected at the end of semester revealed that higher sense of coherence was consistently related to achieving higher academic grades across all four units of study. Students with higher sense of coherence were more self-regulated in their learning approach. More importantly, the study suggests that sense of coherence may be an explanatory factor for students’ successful adaptation and transition in higher education, as indicated by the positive relationship of sense of coherence to academic performance. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Sense of coherence Academic performance Learning strategies Self-regulated learning Cluster analysis Survey design
Introduction Nurses of the future need to be well-prepared to meet the challenges of an increasingly complex and constantly changing healthcare environment (Victorian Government Department of Human Services, 2006). For this to occur, it is crucial that undergraduate nursing education programs provide a solid foundation of
* Corresponding author. E-mail addresses: [email protected] (Y. Salamonson), l.ramjan@uws. edu.au (L.M. Ramjan), [email protected] (S. van den Nieuwenhuizen), [email protected] (L. Metcalfe), [email protected]. au (S. Chang), [email protected] (B. Everett). 1 Centre for Applied Nursing Research (CANR), Ingham Institute for Applied Medical Research.
education and training to ensure that all graduates are able to deliver quality nursing care. Within this context of changing workforce needs, higher education has experienced a radical shift in the past two decades, from learning institutions that cater for elite groups to providing for the masses, with a drive towards social inclusion (Osborne, 2003). University admission now extends far beyond that of traditional students to include non-traditional students from diverse backgrounds and entry levels (Hinton-Smith, 2012). Often, this latter group of students have family and financial commitments, which contribute to the challenges they may experience in meeting the academic demands of their studies (McCarey et al., 2007; Trotter and Roberts, 2006). This often leads to academic underperformance, which has been identified as a key factor for involuntary attrition from undergraduate nursing programs (Jeffreys, 2007; Salamonson et al., 2011).
http://dx.doi.org/10.1016/j.nepr.2016.01.001 1471-5953/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
2
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
Academic performance among nursing students is influenced by a myriad of factors (Salamonson et al., 2011). Although the levels of English usage (Salamonson et al., 2013), and the amount of time spent in paid work during semester time (Reyes et al., 2012; Salamonson et al., 2012) have been shown to influence the academic performance of nursing students in English-speaking countries, studies undertaken in non-English countries reported academic performance was affected positively by academic and social integration among college students (Rienties et al., 2012; Wang and Hannes, 2014). While a number of studies have examined sociodemographic factors associated with academic attainment (Jeffreys, 2007; Korvick et al., 2008; McCarey et al., 2007), few studies have focused on psychological strengths as determinants of academic performance among students in higher education (Cuellar and Zaiontz, 2012; Van Westhuizen et al., 2011). Sense of coherence One of these psychological strengths is the sense of coherence, a person's life orientation which is reflected by their ability to cope with stressful or difficult situations (Eriksson, 2011; Super et al., 2014). The sense of coherence construct was formulated by a medical sociologist, Aaron Antonovsky (1987), who anglicised the Latin word (salus ¼ health) and added the Greek word (genesis ¼ origin), and coined a new word ‘salutogenesis’, as a contrast to the pathogenesis model of medicine. Three components of this construct as outlined by Antonovsky (1987) are: a) comprehensibility (stimuli from one's internal and external environments as being structured and predictable); b) manageability (sufficient resources to meet the demands); and c) meaningfulness (challenges and demands are worthy of engagement and investment). A strong sense of coherence predicts good health and protects against anxiety, depression and burnout (Eriksson, 2011; Foureur et al., 2013; Kikuchi et al., 2014). In a prospective 3-year followup study of over 12,000 adults, a weak sense of coherence was associated with higher mortality (Super et al., 2014). However, in relation to workforce and educational research, the evidence between sense of coherence and coping behaviour, including academic outcome, is inconsistent (Cohen et al., 2008; Collins, 2015; Grayson, 2007). Self-regulated learning strategies Another psychological strength examined in the study is the use of self-regulated learning strategies. Self-regulated learning describes how learners control their thoughts, and behaviours in order to achieve academically (Zimmerman and Schunk, 2011). Students who employ self-regulated learning strategies have higher levels of self-efficacy and perceive the learning task as having value, enabling higher levels of academic performance to be achieved (Pintrich and de Groot, 1990; Salamonson et al., 2009). Aim of study The purpose of this study was to examine the relationship between sense of coherence, self-regulated learning and academic performance. Methods A prospective correlational study design was used to examine the relationships between sense of coherence, components of selfregulated learning and academic performance of first year nursing students.
Study setting and sample The study recruited nursing students from a large university in the western region of Sydney, Australia who were undertaking the standard 3-year undergraduate nursing degree. The survey was administered to first year students in Semester 2 at the end of 2009. Measures Two standardised measures were used: the 13-item Sense of Coherence scale; and the Elaboration, Organization, Rehearsal, Selfefficacy, and Task value scales of the Motivation Strategies for Learning Questionnaire (MSLQ). Sense of Coherence Antonovsky's 13-item scale was used to assess the three dimensions of sense of coherence: comprehensibility, manageability and meaningfulness. This 7-point Likert scale ranges from 1 to 7. Total sense of coherence scores are obtained by summing respondents' scores, which can range from 13 (lowest) to 91 (highest). Previous reports of the internal consistency of this scale ranged from 0.74 to 0.95 (Wolff and Ratner, 1999). In the current study, Principal Components Analysis yielded a one-component solution which explained 30.46% of the variance. The internal consistency of this 13-item scale as assessed by Cronbach's alpha was 0.80. Learning strategies scales Five learning strategies scales of the MSLQ were used to measure the cognitive (Elaboration, Organization and Rehearsal) and motivational (Self-efficacy and Task value) constructs of learning strategies (Duncan and McKeachie, 2005). For example, content assessed in the Elaboration construct included paraphrasing and summarising; and content assessed in the Organisation construct included strategies such as outlining and creating tables. The response format ranged from 1 (not at all true of me) to 7 (very true of me). The results were consistent with previous studies (Duncan and McKeachie, 2005; Salamonson et al., 2009), showing that these scales have good internal consistency. Results of Cronbach's alpha of the 5 scales were: a) Elaboration e 0.85; b) Organization e 0.77; c) Rehearsal e 0.78; d) Self-efficacy e 0.93; and e) Task value e 0.76. In addition to these standardised measures, single-item measures were used to collect sociodemographic information from study participants. For participants who provided consent for linkage of their completed survey to their assessment marks at the end of the semester, results were retrieved from the institutional administrative database. Procedure and ethical consideration Prior to undertaking the study, we sought approval from the university human research ethics committee. Before distributing the surveys to first year students at the end of a bioscience tutorial session during the early weeks of Semester 2, they were informed that involvement in the study was voluntary, information collected was confidential, and only aggregated data would be used in the dissemination of study findings. The students were also briefed and a study information sheet was distributed. Consent was sought from survey respondents to link their completed surveys to their academic grades; students were informed about their rights of non-participation or withdrawal from the study, without affecting their relationship with the researchers then, or in the future.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
Data analysis All statistical analyses were conducted using SPSS Version 22. Cronbach's coefficients were computed to determine the internal reliability of the overall sense of coherence scale and subscales. To identify respondents with natural groupings of sense of coherence subscale (comprehensibility, manageability, and meaningfulness) scores, hierarchical cluster analysis using a within-groups linkage cluster method using Euclidean distances to separate the clusters was chosen. We explored a two-to a four-cluster solution. The optimum number of clusters was selected based on the change of agglomeration coefficients between each of the cluster solutions (Burns and Burns, 2008). A three-cluster solution emerged as the best fit in terms of the similarity of students' responses to the sense of coherence subscales as well as inter-cluster heterogeneity (Aldenderfer and Blashfield, 1984). One-way ANOVA test was used to compare for group differences in sense of coherence subscales and learning strategies scores, and academic grades in bioscience. Stepwise multiple linear regression was performed using the average academic grades of all four units of study as the dependent variable and the following six independent variables: i) mature-age entry (up to 21 years versus more than 21 years); ii) gender (males versus females); iii) language usage (spoke other than English versus English-speaking only); iv) hours in paid work during termtime (up to 16 h per week). A p value of less than 0.05 was set as the threshold for statistical significance. Results Cluster analysis In Fig. 1, the number of respondents in each of the three clusters based on sense of coherence subscale score levels were 225 (40% e low), 234 (42% e medium), and 104 (18% e high) respectively. The three cluster profiles were compared with the three main groups of variables of interest: a) sociodemographic variables (age, gender, country of birth and paid work engagement); b) learning strategies (Elaborative, Organization, Rehearsal, Self-efficacy, and Task value); and c) academic performance in each nursing unit at the end of the semester (overall grades in: Professional Nursing, Bioscience, Nursing Sociology, and Nursing Practice). Comparison of sense of coherence clusters and sociodemographic characteristics Table 1 presents a comparison of sociodemographic characteristics of students across the three sense of coherence clusters. There were no statistically significant differences in sociodemographic characteristics between the three clusters. Comparison of sense of coherence clusters and self-regulated learning Fig. 2 shows that students in the higher sense of coherence clusters were consistently more likely to self-report using all five components of learning strategies as an indication of self-regulated learning: elaboration (p ¼ 0.004); organisation (p ¼ 0.007); rehearsal (p ¼ 0.013); self-efficacy (p < 0.001); and task value (p < 0.001). Comparison of sense of coherence clusters and end-of-year academic performance The end-of-year academic performance indicated by the academic grades achieved in all four units of enrolment also
3
demonstrated that students with higher sense of coherence cluster scores were consistently more likely to achieve higher academic grades in all four nursing subjects (Fig. 3). Multivariate analysis: predictors of end-of-year academic performance In order to examine if the sense of coherence cluster scores, selfregulated learning scores, and scoiodemographic variables used were predictive of students’ academic grades across the four units of study, stepwise multiple regression analysis was performed. Controlling for language usage and hours spent in paid work during term-time, self-regulated learning strategies and sense of coherence cluster scores emerged as statistically significant predictors of end-of-year academic performance across the four units of study (Table 2). Discussion In this prospective follow-up study of a group of first year undergraduate nursing students, high sense of coherence was shown to be predictive of higher academic grades. This result is consistent with recent reported study findings that demonstrated a direct association between higher sense of coherence and academic achievement (Winding et al., 2013), and adaptive coping behaviours (Collins, 2015; Kikuchi et al., 2014; Skodova and Lajciakova, 2013; Ward et al., 2014). However, it also needs to be acknowledged that there were also other studies that failed to establish this association (Cohen et al., 2008; Ying et al., 2001). The current study was undertaken in a culturally and linguistically diverse region of western Sydney, and thus was able to examine the effects of sociodemographic characteristics on academic performance, and at the same time, gain insight into the impact psychological factors such as sense of coherence have on academic performance. It is possible that students with a high sense of coherence were more likely to have the skills to cope with transitioning to university life; hence, when facing academicrelated difficulties, they may be more likely to source learning strategies and academic resources (such as academic literacy, tutor assistance) to support them through their studies (Salamonson et al., 2009). Additionally, those with a higher sense of coherence are likely to be more motivated to learn and engage in classroom discussions (Grayson, 2008), and use problem-focused coping strategies (Cohen et al., 2008). The results also suggest that those with higher sense of coherence were more likely to utilise adaptive coping skills (Ando et al., 2011; Foureur et al., 2013); among students, these included adopting self-regulated learning strategies that enhanced their likelihood of academic success (West and Sadoski, 2011; Zimmerman and Schunk, 2011). This finding is consistent with the study of Van Westhuizen et al. (2011), who reported that selfefficacy, together with sense of coherence, were predictors of academic success. Despite the literature on sense of coherence being predominantly related to health and coping, a limited number of studies have measured sense of coherence in relation to academic perfor€ mance (Grayson, 2008; Kristensson and Ohlund, 2005; Ying et al., 2001). Adding to this body of literature, our study showed that nursing students with low sense of coherence underperformed academically in the first year of their course when sociodemographic factors were taken into consideration. Further, our study provides support for considering inclusion of measures of psychological constructs (e.g. sense of coherence) as screening tools to identify students who may be at risk of underperformance. Underperformance in the first year of a nursing course could be an
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
4
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
Fig. 1. Sense of Coherence (SOC) subscales cluster groups (n ¼ 563).
early warning sign of course attrition, or students who are at risk of delayed course completion (Salamonson et al., 2011). Hence, it may be worthwhile to identify students with low sense of coherence in order to offer early and timely academic support during the course of their nursing studies. A number of study limitations need to be acknowledged. First, except for academic grades, the study relied solely on self-report measures that may be subject to recall bias (Bowman, 2010). Second, both sense of coherence and self-regulated learning strategies were only measured at baseline. Learning strategies utilised by first
year students are likely to change during the period of transitioning into higher education; similarly an individual's sense of coherence can also change if confronted with major life events (Collins, 2015). Third, although several variables were found to be predictive of academic performance, the effect size as noted by the standardised beta was small. This could mean that the contributory impact of sense of coherence to academic performance may be trivial and may not be relevant in this setting. This limitation will need further exploration in future studies. However, there were also study strengths that are worth noting. Students' academic grades were
Table 1 Sociodemographic characteristics of low, medium and high sense of coherence groups (n ¼ 563). Characteristics
Age, mean (SD) Gender: Female, n (%) Country of birth: Australia, n (%) Engaged in paid work: Yes, n (%)
Sense of coherence scores
p Value
Low (n ¼ 225)
Medium (n ¼ 234)
High (n ¼ 104)
22.6 187 111 141
24.5 182 107 165
23.8 86 58 71
(6.5) (83) (49) (63)
(8.1) (78) (46) (71)
(6.9) (83) (56) (68)
0.070 0.302 0.232 0.193
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
5
Fig. 2. Comparison of learning strategies with Sense of Coherence clusters.
Fig. 3. Comparison of subject grades with Sense of Coherence clusters.
Table 2 Stepwise multiple regression: Predictors of participants’ academic performance across four units of study. Variables
Beta
SE
p
Mean overall grades across four units of study Sense of coherence clusters (Reference: Low sense of coherence) o Medium sense of coherence cluster o High sense of coherence cluster Mean overall self-regulated learning strategies (Elaboration, Organisation, Rehearsal, Self-efficacy, and Task value) Language usage (English only) Paid work during term-time: >16 h per week
0.14 0.12 0.09 0.19 0.12
1.10 1.42 0.11 1.02 1.05
0.002 0.010 0.036 <0.001 0.006
Overall model: R ¼ 0.279, F(df) ¼ 8.88 (5, 528), p < 0.001, adjusted R2 ¼ 0.069.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
6
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
obtained at the end-of-semester from official administrative data, not based on subjective reports of participants. Additionally, with the large sample size, prospective follow-up study design and use of only validated measures to examine the constructs of interest were important study strengths. Conclusion Overall the study provides further evidence that students' sense of coherence affects their academic performance. Furthermore, the results also indicate that in addition to the established sociodemographic factors that are related to academic performance of nursing students, psychological strengths also predict academic success. Therefore, positive psychological constructs such as sense of coherence are worthy of consideration as screening measures, to ensure that high-risk groups are recognised early and provided the necessary academic support to facilitate study progression and prevent students leaving the nursing course prior to course completion. Conflict of interest No conflict of interest has been declared by the authors. Author contributions YS was responsible for the study conception and design, organised the data collection and performed the data analysis. YS, BE, LR, SVDN, LM and SC were responsible for drafting the manuscript. YS, BE, LR, SVDN, LM and SC made critical revisions to the paper for important intellectual content. References Aldenderfer, M.S., Blashfield, R.K., 1984. Cluster Analysis. Sage Publications, Inc., Newbury Park, California. Ando, M., Natsume, T., Kukihara, H., Shibata, H., Ito, S., 2011. Efficacy of mindfulnessbased meditation therapy on the sense of coherence and mental health of nurses. Health 3 (02), 118. Antonovsky, A., 1987. Unraveling the Mystery of Health: How People Manage Stress and Stay Well. Jossey-Bass, San Francisco, CA. Bowman, N.A., 2010. Can 1st-year college students accurately report their learning and development? Am. Educ. Res. J. 47 (2), 466e496. Burns, R.B., Burns, R.A., 2008. Cluster analysis. In: Business Research Methods and Statistics Using SPSS. Sage, London, pp. 552e558. Cohen, M., Ben-Zur, H., Rosenfeld, M.J., 2008. Sense of coherence, coping strategies, and test anxiety as predictors of test performance among college students. Int. J. Stress Manag. 15 (3), 289e303. Collins, S., 2015. Alternative psychological approaches for social workers and social work students dealing with stress in the UK: sense of coherence, challenge appraisals, self-efficacy and sense of control. Br. J. Soc. Work 45 (1), 69e85. Cuellar, E.H., Zaiontz, R.G., 2012. Salutogenic nursing education: a summative review. J. Nurs. Educ. Pract. 3 (5), 89e101. Duncan, T.G., McKeachie, W.J., 2005. The making of the motivated strategies for learning questionnaire. Educ. Psychol. 40 (2), 117e128. Eriksson, M., 2011. Sense of coherence across the life course. Findings from a systematic review 1992e2010. In: Paper Presented at the International Conference on Assets for Health and Wellbeing across the Life Course (26e27th September 2011), London, UK. Foureur, M., Besley, K., Burton, G., Yu, N., Crisp, J., 2013. Enhancing the resilience of nurses and midwives: pilot of a mindfulnessbased program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp. Nurse 45 (1), 114e125.
Grayson, J.P., 2007. Sense of coherence, problem freedom and academic outcomes of Canadian domestic and international students. Qual. High. Educ. 13 (3), 215e236. Grayson, J.P., 2008. Sense of coherence and academic achievement of domestic and international students: a comparative analysis. High. Educ. 56 (4), 473e492. Hinton-Smith, T. (Ed.), 2012. Widening Participation in Higher Education: Casting the Net Wide?. Palgrave Macmillan, London. Jeffreys, M.R., 2007. Tracking students through program entry, progression, graduation, and licensure: assessing undergraduate nursing student retention and success. Nurse Educ. Today 27 (5), 406e419. Kikuchi, Y., Nakaya, M., Ikeda, M., Okuzumi, S., Takeda, M., Nishi, M., 2014. Relationship between depressive state, job stress, and sense of coherence among female nurses. Indian J. Occup. Environ. Med. 18 (1), 32. Korvick, L.M., Wisener, L.K., Loftis, L.A., Williamson, M.L., 2008. Comparing the academic performance of students in traditional and second-degree baccalaureate programs. J. Nurs. Educ. 47 (3), 139e141. € Kristensson, P., Ohlund, L.S., 2005. Swedish upper secondary school pupils' sense of coherence, coping resources and aggressiveness in relation to educational track and performance. Scand. J. Caring Sci. 19 (1), 77e84. McCarey, M., Barr, T., Rattray, J., 2007. Predictors of academic performance in a cohort of pre-registration nursing students. Nurse Educ. Today 27 (4), 357e364. Osborne, M., 2003. Policy and practice in widening participation: a six country comparative study of access as flexibility. Int. J. Lifelong Educ. 22 (1), 43e58. Pintrich, P.R., de Groot, E.V., 1990. Motivational and self-regulated learning components of classroom academic performance. J. Educ. Psychol. 82 (1), 33e40. Reyes, H., Hartin, V., Loftin, C., Davenport, D., Carter, V., 2012. The impact of employment on nursing students' academic performance. Nurse Educ. 37 (5), 218e221. Rienties, B., Beausaert, S., Grohnert, T., Niemantsverdriet, S., Kommers, P., 2012. Understanding academic performance of international students: the role of ethnicity, academic and social integration. High. Educ. 63 (6), 685e700. Salamonson, Y., Andrew, S., Clauson, J., Jacobs, S., Cleary, M., Jackson, D., 2011. Linguistic diversity as sociodemographic predictor of nursing program progression and completion. Contemp. Nurse 38 (1e2), 84e93. Salamonson, Y., Attwood, N., Everett, B., Weaver, R., Glew, P., 2013. Psychometric testing of the English Language Acculturation Scale in first-year nursing students. J. Adv. Nurs. 69 (10), 2309e2316. Salamonson, Y., Everett, B., Koch, J., Andrew, S., Davidson, P.M., 2012. The impact of term-time paid work on academic performance in nursing students: a longitudinal study. Int. J. Nurs. Stud. 49 (5), 579e585. Salamonson, Y., Everett, B., Koch, J., Wilson, I., Davidson, P.M., 2009. Learning strategies of first year nursing and medical students: a comparative study. Int. J. Nurs. Stud. 46 (12), 1541e1547. Skodova, Z., Lajciakova, P., 2013. The effect of personality traits and psychosocial training on burnout syndrome among healthcare students. Nurse Educ. Today 33 (11), 1311e1315. Super, S., Verschuren, W.M., Zantinge, E.M., Wagemakers, M.A.E., Picavet, H.S.J., 2014. A weak sense of coherence is associated with a higher mortality risk. J. Epidemiol. Commun. Health. Published Online First 2 January 2014, jech2013-203085. Trotter, E., Roberts, C.A., 2006. Enhancing the early student experience. High. Educ. Res. Dev. 25 (4), 371e386. Van Westhuizen, S.D., De Beer, M., Bekwa, N., 2011. Psychological strengths as predictors of postgraduate students' academic achievement. J. Psychol. Afr. 21 (3), 473e478. Victorian Government Department of Human Services, 2006. Prepare Nurses for the Future (Report e Phase 1) Nurse Policy Branch. Retrieved 7 July, 2013, from: http://www.health.vic.gov.au/__data/assets/pdf_file/0003/17652/ preparenurses_phase1.pdf. Wang, Q., Hannes, K., 2014. Academic and socio-cultural adjustment among Asian international students in the Flemish community of Belgium: a photovoice project. Int. J. Intercult. Relat. 39, 66e81. Ward, M., Schulz, M., Bruland, D., 2014. A systematic review of Antonovsky's Sense of Coherence scale and its use in studies among nurses: implications for psychiatric and mental health nursing. J. Psychiatric Nurs. 5 (2), 61e71. West, C., Sadoski, M., 2011. Do study strategies predict academic performance in medical school? Med. Educ. 45 (7), 696e703. Wolff, A.C., Ratner, P.A., 1999. Stress, social support, and sense of coherence. West. J. Nurs. Res. 21 (2), 182e197. Ying, Y.W., Lee, P.A., Tsai, J.L., Hung, Y., Lin, M., Wan, C.T., 2001. Asian American college students as model minorities: an examination of their overall competence. Cult. Divers. Ethn. Minority Psychol. 7 (1), 59e74. Zimmerman, B.J., Schunk, D.H., 2011. Self-regulated Learning and Performance. Taylor & Francis, New York, USA.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach Yenna Salamonson a, *, 1, Lucie M. Ramjan a, 1, Simon van den Nieuwenhuizen a, Lauren Metcalfe a, 1, Sungwon Chang b, Bronwyn Everett a, c, 1 a
University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith, NSW 2751, Australia University of Western Sydney, School of Nursing and Midwifery & Postdoctoral Research Fellow, University of Technology Sydney, Faculty of Health, Level 7, Building 10, City Campus, PO Box 123, Broadway, NSW 2007, Australia c University of Western Sydney, South Western Sydney Local Health District (SWSLHD), Locked Bag 7103, Liverpool BC, NSW 1871, Australia b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 18 September 2014 Received in revised form 8 August 2015 Accepted 4 January 2016
This paper examines the relationship between nursing students' sense of coherence, self-regulated learning and academic performance in bioscience. While there is increasing recognition of a need to foster students' self-regulated learning, little is known about the relationship of psychological strengths, particularly sense of coherence and academic performance. Using a prospective, correlational design, 563 first year nursing students completed the three dimensions of sense of coherence scale e comprehensibility, manageability and meaningfulness, and five components of self-regulated learning strategy e elaboration, organisation, rehearsal, self-efficacy and task value. Cluster analysis was used to group respondents into three clusters, based on their sense of coherence subscale scores. Although there were no sociodemographic differences in sense of coherence subscale scores, those with higher sense of coherence were more likely to adopt self-regulated learning strategies. Furthermore, academic grades collected at the end of semester revealed that higher sense of coherence was consistently related to achieving higher academic grades across all four units of study. Students with higher sense of coherence were more self-regulated in their learning approach. More importantly, the study suggests that sense of coherence may be an explanatory factor for students’ successful adaptation and transition in higher education, as indicated by the positive relationship of sense of coherence to academic performance. © 2016 Elsevier Ltd. All rights reserved.
Keywords: Sense of coherence Academic performance Learning strategies Self-regulated learning Cluster analysis Survey design
Introduction Nurses of the future need to be well-prepared to meet the challenges of an increasingly complex and constantly changing healthcare environment (Victorian Government Department of Human Services, 2006). For this to occur, it is crucial that undergraduate nursing education programs provide a solid foundation of
* Corresponding author. E-mail addresses: [email protected] (Y. Salamonson), l.ramjan@uws. edu.au (L.M. Ramjan), [email protected] (S. van den Nieuwenhuizen), [email protected] (L. Metcalfe), [email protected]. au (S. Chang), [email protected] (B. Everett). 1 Centre for Applied Nursing Research (CANR), Ingham Institute for Applied Medical Research.
education and training to ensure that all graduates are able to deliver quality nursing care. Within this context of changing workforce needs, higher education has experienced a radical shift in the past two decades, from learning institutions that cater for elite groups to providing for the masses, with a drive towards social inclusion (Osborne, 2003). University admission now extends far beyond that of traditional students to include non-traditional students from diverse backgrounds and entry levels (Hinton-Smith, 2012). Often, this latter group of students have family and financial commitments, which contribute to the challenges they may experience in meeting the academic demands of their studies (McCarey et al., 2007; Trotter and Roberts, 2006). This often leads to academic underperformance, which has been identified as a key factor for involuntary attrition from undergraduate nursing programs (Jeffreys, 2007; Salamonson et al., 2011).
http://dx.doi.org/10.1016/j.nepr.2016.01.001 1471-5953/© 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
2
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
Academic performance among nursing students is influenced by a myriad of factors (Salamonson et al., 2011). Although the levels of English usage (Salamonson et al., 2013), and the amount of time spent in paid work during semester time (Reyes et al., 2012; Salamonson et al., 2012) have been shown to influence the academic performance of nursing students in English-speaking countries, studies undertaken in non-English countries reported academic performance was affected positively by academic and social integration among college students (Rienties et al., 2012; Wang and Hannes, 2014). While a number of studies have examined sociodemographic factors associated with academic attainment (Jeffreys, 2007; Korvick et al., 2008; McCarey et al., 2007), few studies have focused on psychological strengths as determinants of academic performance among students in higher education (Cuellar and Zaiontz, 2012; Van Westhuizen et al., 2011). Sense of coherence One of these psychological strengths is the sense of coherence, a person's life orientation which is reflected by their ability to cope with stressful or difficult situations (Eriksson, 2011; Super et al., 2014). The sense of coherence construct was formulated by a medical sociologist, Aaron Antonovsky (1987), who anglicised the Latin word (salus ¼ health) and added the Greek word (genesis ¼ origin), and coined a new word ‘salutogenesis’, as a contrast to the pathogenesis model of medicine. Three components of this construct as outlined by Antonovsky (1987) are: a) comprehensibility (stimuli from one's internal and external environments as being structured and predictable); b) manageability (sufficient resources to meet the demands); and c) meaningfulness (challenges and demands are worthy of engagement and investment). A strong sense of coherence predicts good health and protects against anxiety, depression and burnout (Eriksson, 2011; Foureur et al., 2013; Kikuchi et al., 2014). In a prospective 3-year followup study of over 12,000 adults, a weak sense of coherence was associated with higher mortality (Super et al., 2014). However, in relation to workforce and educational research, the evidence between sense of coherence and coping behaviour, including academic outcome, is inconsistent (Cohen et al., 2008; Collins, 2015; Grayson, 2007). Self-regulated learning strategies Another psychological strength examined in the study is the use of self-regulated learning strategies. Self-regulated learning describes how learners control their thoughts, and behaviours in order to achieve academically (Zimmerman and Schunk, 2011). Students who employ self-regulated learning strategies have higher levels of self-efficacy and perceive the learning task as having value, enabling higher levels of academic performance to be achieved (Pintrich and de Groot, 1990; Salamonson et al., 2009). Aim of study The purpose of this study was to examine the relationship between sense of coherence, self-regulated learning and academic performance. Methods A prospective correlational study design was used to examine the relationships between sense of coherence, components of selfregulated learning and academic performance of first year nursing students.
Study setting and sample The study recruited nursing students from a large university in the western region of Sydney, Australia who were undertaking the standard 3-year undergraduate nursing degree. The survey was administered to first year students in Semester 2 at the end of 2009. Measures Two standardised measures were used: the 13-item Sense of Coherence scale; and the Elaboration, Organization, Rehearsal, Selfefficacy, and Task value scales of the Motivation Strategies for Learning Questionnaire (MSLQ). Sense of Coherence Antonovsky's 13-item scale was used to assess the three dimensions of sense of coherence: comprehensibility, manageability and meaningfulness. This 7-point Likert scale ranges from 1 to 7. Total sense of coherence scores are obtained by summing respondents' scores, which can range from 13 (lowest) to 91 (highest). Previous reports of the internal consistency of this scale ranged from 0.74 to 0.95 (Wolff and Ratner, 1999). In the current study, Principal Components Analysis yielded a one-component solution which explained 30.46% of the variance. The internal consistency of this 13-item scale as assessed by Cronbach's alpha was 0.80. Learning strategies scales Five learning strategies scales of the MSLQ were used to measure the cognitive (Elaboration, Organization and Rehearsal) and motivational (Self-efficacy and Task value) constructs of learning strategies (Duncan and McKeachie, 2005). For example, content assessed in the Elaboration construct included paraphrasing and summarising; and content assessed in the Organisation construct included strategies such as outlining and creating tables. The response format ranged from 1 (not at all true of me) to 7 (very true of me). The results were consistent with previous studies (Duncan and McKeachie, 2005; Salamonson et al., 2009), showing that these scales have good internal consistency. Results of Cronbach's alpha of the 5 scales were: a) Elaboration e 0.85; b) Organization e 0.77; c) Rehearsal e 0.78; d) Self-efficacy e 0.93; and e) Task value e 0.76. In addition to these standardised measures, single-item measures were used to collect sociodemographic information from study participants. For participants who provided consent for linkage of their completed survey to their assessment marks at the end of the semester, results were retrieved from the institutional administrative database. Procedure and ethical consideration Prior to undertaking the study, we sought approval from the university human research ethics committee. Before distributing the surveys to first year students at the end of a bioscience tutorial session during the early weeks of Semester 2, they were informed that involvement in the study was voluntary, information collected was confidential, and only aggregated data would be used in the dissemination of study findings. The students were also briefed and a study information sheet was distributed. Consent was sought from survey respondents to link their completed surveys to their academic grades; students were informed about their rights of non-participation or withdrawal from the study, without affecting their relationship with the researchers then, or in the future.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
Data analysis All statistical analyses were conducted using SPSS Version 22. Cronbach's coefficients were computed to determine the internal reliability of the overall sense of coherence scale and subscales. To identify respondents with natural groupings of sense of coherence subscale (comprehensibility, manageability, and meaningfulness) scores, hierarchical cluster analysis using a within-groups linkage cluster method using Euclidean distances to separate the clusters was chosen. We explored a two-to a four-cluster solution. The optimum number of clusters was selected based on the change of agglomeration coefficients between each of the cluster solutions (Burns and Burns, 2008). A three-cluster solution emerged as the best fit in terms of the similarity of students' responses to the sense of coherence subscales as well as inter-cluster heterogeneity (Aldenderfer and Blashfield, 1984). One-way ANOVA test was used to compare for group differences in sense of coherence subscales and learning strategies scores, and academic grades in bioscience. Stepwise multiple linear regression was performed using the average academic grades of all four units of study as the dependent variable and the following six independent variables: i) mature-age entry (up to 21 years versus more than 21 years); ii) gender (males versus females); iii) language usage (spoke other than English versus English-speaking only); iv) hours in paid work during termtime (up to 16 h per week). A p value of less than 0.05 was set as the threshold for statistical significance. Results Cluster analysis In Fig. 1, the number of respondents in each of the three clusters based on sense of coherence subscale score levels were 225 (40% e low), 234 (42% e medium), and 104 (18% e high) respectively. The three cluster profiles were compared with the three main groups of variables of interest: a) sociodemographic variables (age, gender, country of birth and paid work engagement); b) learning strategies (Elaborative, Organization, Rehearsal, Self-efficacy, and Task value); and c) academic performance in each nursing unit at the end of the semester (overall grades in: Professional Nursing, Bioscience, Nursing Sociology, and Nursing Practice). Comparison of sense of coherence clusters and sociodemographic characteristics Table 1 presents a comparison of sociodemographic characteristics of students across the three sense of coherence clusters. There were no statistically significant differences in sociodemographic characteristics between the three clusters. Comparison of sense of coherence clusters and self-regulated learning Fig. 2 shows that students in the higher sense of coherence clusters were consistently more likely to self-report using all five components of learning strategies as an indication of self-regulated learning: elaboration (p ¼ 0.004); organisation (p ¼ 0.007); rehearsal (p ¼ 0.013); self-efficacy (p < 0.001); and task value (p < 0.001). Comparison of sense of coherence clusters and end-of-year academic performance The end-of-year academic performance indicated by the academic grades achieved in all four units of enrolment also
3
demonstrated that students with higher sense of coherence cluster scores were consistently more likely to achieve higher academic grades in all four nursing subjects (Fig. 3). Multivariate analysis: predictors of end-of-year academic performance In order to examine if the sense of coherence cluster scores, selfregulated learning scores, and scoiodemographic variables used were predictive of students’ academic grades across the four units of study, stepwise multiple regression analysis was performed. Controlling for language usage and hours spent in paid work during term-time, self-regulated learning strategies and sense of coherence cluster scores emerged as statistically significant predictors of end-of-year academic performance across the four units of study (Table 2). Discussion In this prospective follow-up study of a group of first year undergraduate nursing students, high sense of coherence was shown to be predictive of higher academic grades. This result is consistent with recent reported study findings that demonstrated a direct association between higher sense of coherence and academic achievement (Winding et al., 2013), and adaptive coping behaviours (Collins, 2015; Kikuchi et al., 2014; Skodova and Lajciakova, 2013; Ward et al., 2014). However, it also needs to be acknowledged that there were also other studies that failed to establish this association (Cohen et al., 2008; Ying et al., 2001). The current study was undertaken in a culturally and linguistically diverse region of western Sydney, and thus was able to examine the effects of sociodemographic characteristics on academic performance, and at the same time, gain insight into the impact psychological factors such as sense of coherence have on academic performance. It is possible that students with a high sense of coherence were more likely to have the skills to cope with transitioning to university life; hence, when facing academicrelated difficulties, they may be more likely to source learning strategies and academic resources (such as academic literacy, tutor assistance) to support them through their studies (Salamonson et al., 2009). Additionally, those with a higher sense of coherence are likely to be more motivated to learn and engage in classroom discussions (Grayson, 2008), and use problem-focused coping strategies (Cohen et al., 2008). The results also suggest that those with higher sense of coherence were more likely to utilise adaptive coping skills (Ando et al., 2011; Foureur et al., 2013); among students, these included adopting self-regulated learning strategies that enhanced their likelihood of academic success (West and Sadoski, 2011; Zimmerman and Schunk, 2011). This finding is consistent with the study of Van Westhuizen et al. (2011), who reported that selfefficacy, together with sense of coherence, were predictors of academic success. Despite the literature on sense of coherence being predominantly related to health and coping, a limited number of studies have measured sense of coherence in relation to academic perfor€ mance (Grayson, 2008; Kristensson and Ohlund, 2005; Ying et al., 2001). Adding to this body of literature, our study showed that nursing students with low sense of coherence underperformed academically in the first year of their course when sociodemographic factors were taken into consideration. Further, our study provides support for considering inclusion of measures of psychological constructs (e.g. sense of coherence) as screening tools to identify students who may be at risk of underperformance. Underperformance in the first year of a nursing course could be an
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
4
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
Fig. 1. Sense of Coherence (SOC) subscales cluster groups (n ¼ 563).
early warning sign of course attrition, or students who are at risk of delayed course completion (Salamonson et al., 2011). Hence, it may be worthwhile to identify students with low sense of coherence in order to offer early and timely academic support during the course of their nursing studies. A number of study limitations need to be acknowledged. First, except for academic grades, the study relied solely on self-report measures that may be subject to recall bias (Bowman, 2010). Second, both sense of coherence and self-regulated learning strategies were only measured at baseline. Learning strategies utilised by first
year students are likely to change during the period of transitioning into higher education; similarly an individual's sense of coherence can also change if confronted with major life events (Collins, 2015). Third, although several variables were found to be predictive of academic performance, the effect size as noted by the standardised beta was small. This could mean that the contributory impact of sense of coherence to academic performance may be trivial and may not be relevant in this setting. This limitation will need further exploration in future studies. However, there were also study strengths that are worth noting. Students' academic grades were
Table 1 Sociodemographic characteristics of low, medium and high sense of coherence groups (n ¼ 563). Characteristics
Age, mean (SD) Gender: Female, n (%) Country of birth: Australia, n (%) Engaged in paid work: Yes, n (%)
Sense of coherence scores
p Value
Low (n ¼ 225)
Medium (n ¼ 234)
High (n ¼ 104)
22.6 187 111 141
24.5 182 107 165
23.8 86 58 71
(6.5) (83) (49) (63)
(8.1) (78) (46) (71)
(6.9) (83) (56) (68)
0.070 0.302 0.232 0.193
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
5
Fig. 2. Comparison of learning strategies with Sense of Coherence clusters.
Fig. 3. Comparison of subject grades with Sense of Coherence clusters.
Table 2 Stepwise multiple regression: Predictors of participants’ academic performance across four units of study. Variables
Beta
SE
p
Mean overall grades across four units of study Sense of coherence clusters (Reference: Low sense of coherence) o Medium sense of coherence cluster o High sense of coherence cluster Mean overall self-regulated learning strategies (Elaboration, Organisation, Rehearsal, Self-efficacy, and Task value) Language usage (English only) Paid work during term-time: >16 h per week
0.14 0.12 0.09 0.19 0.12
1.10 1.42 0.11 1.02 1.05
0.002 0.010 0.036 <0.001 0.006
Overall model: R ¼ 0.279, F(df) ¼ 8.88 (5, 528), p < 0.001, adjusted R2 ¼ 0.069.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001
6
Y. Salamonson et al. / Nurse Education in Practice xxx (2016) 1e6
obtained at the end-of-semester from official administrative data, not based on subjective reports of participants. Additionally, with the large sample size, prospective follow-up study design and use of only validated measures to examine the constructs of interest were important study strengths. Conclusion Overall the study provides further evidence that students' sense of coherence affects their academic performance. Furthermore, the results also indicate that in addition to the established sociodemographic factors that are related to academic performance of nursing students, psychological strengths also predict academic success. Therefore, positive psychological constructs such as sense of coherence are worthy of consideration as screening measures, to ensure that high-risk groups are recognised early and provided the necessary academic support to facilitate study progression and prevent students leaving the nursing course prior to course completion. Conflict of interest No conflict of interest has been declared by the authors. Author contributions YS was responsible for the study conception and design, organised the data collection and performed the data analysis. YS, BE, LR, SVDN, LM and SC were responsible for drafting the manuscript. YS, BE, LR, SVDN, LM and SC made critical revisions to the paper for important intellectual content. References Aldenderfer, M.S., Blashfield, R.K., 1984. Cluster Analysis. Sage Publications, Inc., Newbury Park, California. Ando, M., Natsume, T., Kukihara, H., Shibata, H., Ito, S., 2011. Efficacy of mindfulnessbased meditation therapy on the sense of coherence and mental health of nurses. Health 3 (02), 118. Antonovsky, A., 1987. Unraveling the Mystery of Health: How People Manage Stress and Stay Well. Jossey-Bass, San Francisco, CA. Bowman, N.A., 2010. Can 1st-year college students accurately report their learning and development? Am. Educ. Res. J. 47 (2), 466e496. Burns, R.B., Burns, R.A., 2008. Cluster analysis. In: Business Research Methods and Statistics Using SPSS. Sage, London, pp. 552e558. Cohen, M., Ben-Zur, H., Rosenfeld, M.J., 2008. Sense of coherence, coping strategies, and test anxiety as predictors of test performance among college students. Int. J. Stress Manag. 15 (3), 289e303. Collins, S., 2015. Alternative psychological approaches for social workers and social work students dealing with stress in the UK: sense of coherence, challenge appraisals, self-efficacy and sense of control. Br. J. Soc. Work 45 (1), 69e85. Cuellar, E.H., Zaiontz, R.G., 2012. Salutogenic nursing education: a summative review. J. Nurs. Educ. Pract. 3 (5), 89e101. Duncan, T.G., McKeachie, W.J., 2005. The making of the motivated strategies for learning questionnaire. Educ. Psychol. 40 (2), 117e128. Eriksson, M., 2011. Sense of coherence across the life course. Findings from a systematic review 1992e2010. In: Paper Presented at the International Conference on Assets for Health and Wellbeing across the Life Course (26e27th September 2011), London, UK. Foureur, M., Besley, K., Burton, G., Yu, N., Crisp, J., 2013. Enhancing the resilience of nurses and midwives: pilot of a mindfulnessbased program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemp. Nurse 45 (1), 114e125.
Grayson, J.P., 2007. Sense of coherence, problem freedom and academic outcomes of Canadian domestic and international students. Qual. High. Educ. 13 (3), 215e236. Grayson, J.P., 2008. Sense of coherence and academic achievement of domestic and international students: a comparative analysis. High. Educ. 56 (4), 473e492. Hinton-Smith, T. (Ed.), 2012. Widening Participation in Higher Education: Casting the Net Wide?. Palgrave Macmillan, London. Jeffreys, M.R., 2007. Tracking students through program entry, progression, graduation, and licensure: assessing undergraduate nursing student retention and success. Nurse Educ. Today 27 (5), 406e419. Kikuchi, Y., Nakaya, M., Ikeda, M., Okuzumi, S., Takeda, M., Nishi, M., 2014. Relationship between depressive state, job stress, and sense of coherence among female nurses. Indian J. Occup. Environ. Med. 18 (1), 32. Korvick, L.M., Wisener, L.K., Loftis, L.A., Williamson, M.L., 2008. Comparing the academic performance of students in traditional and second-degree baccalaureate programs. J. Nurs. Educ. 47 (3), 139e141. € Kristensson, P., Ohlund, L.S., 2005. Swedish upper secondary school pupils' sense of coherence, coping resources and aggressiveness in relation to educational track and performance. Scand. J. Caring Sci. 19 (1), 77e84. McCarey, M., Barr, T., Rattray, J., 2007. Predictors of academic performance in a cohort of pre-registration nursing students. Nurse Educ. Today 27 (4), 357e364. Osborne, M., 2003. Policy and practice in widening participation: a six country comparative study of access as flexibility. Int. J. Lifelong Educ. 22 (1), 43e58. Pintrich, P.R., de Groot, E.V., 1990. Motivational and self-regulated learning components of classroom academic performance. J. Educ. Psychol. 82 (1), 33e40. Reyes, H., Hartin, V., Loftin, C., Davenport, D., Carter, V., 2012. The impact of employment on nursing students' academic performance. Nurse Educ. 37 (5), 218e221. Rienties, B., Beausaert, S., Grohnert, T., Niemantsverdriet, S., Kommers, P., 2012. Understanding academic performance of international students: the role of ethnicity, academic and social integration. High. Educ. 63 (6), 685e700. Salamonson, Y., Andrew, S., Clauson, J., Jacobs, S., Cleary, M., Jackson, D., 2011. Linguistic diversity as sociodemographic predictor of nursing program progression and completion. Contemp. Nurse 38 (1e2), 84e93. Salamonson, Y., Attwood, N., Everett, B., Weaver, R., Glew, P., 2013. Psychometric testing of the English Language Acculturation Scale in first-year nursing students. J. Adv. Nurs. 69 (10), 2309e2316. Salamonson, Y., Everett, B., Koch, J., Andrew, S., Davidson, P.M., 2012. The impact of term-time paid work on academic performance in nursing students: a longitudinal study. Int. J. Nurs. Stud. 49 (5), 579e585. Salamonson, Y., Everett, B., Koch, J., Wilson, I., Davidson, P.M., 2009. Learning strategies of first year nursing and medical students: a comparative study. Int. J. Nurs. Stud. 46 (12), 1541e1547. Skodova, Z., Lajciakova, P., 2013. The effect of personality traits and psychosocial training on burnout syndrome among healthcare students. Nurse Educ. Today 33 (11), 1311e1315. Super, S., Verschuren, W.M., Zantinge, E.M., Wagemakers, M.A.E., Picavet, H.S.J., 2014. A weak sense of coherence is associated with a higher mortality risk. J. Epidemiol. Commun. Health. Published Online First 2 January 2014, jech2013-203085. Trotter, E., Roberts, C.A., 2006. Enhancing the early student experience. High. Educ. Res. Dev. 25 (4), 371e386. Van Westhuizen, S.D., De Beer, M., Bekwa, N., 2011. Psychological strengths as predictors of postgraduate students' academic achievement. J. Psychol. Afr. 21 (3), 473e478. Victorian Government Department of Human Services, 2006. Prepare Nurses for the Future (Report e Phase 1) Nurse Policy Branch. Retrieved 7 July, 2013, from: http://www.health.vic.gov.au/__data/assets/pdf_file/0003/17652/ preparenurses_phase1.pdf. Wang, Q., Hannes, K., 2014. Academic and socio-cultural adjustment among Asian international students in the Flemish community of Belgium: a photovoice project. Int. J. Intercult. Relat. 39, 66e81. Ward, M., Schulz, M., Bruland, D., 2014. A systematic review of Antonovsky's Sense of Coherence scale and its use in studies among nurses: implications for psychiatric and mental health nursing. J. Psychiatric Nurs. 5 (2), 61e71. West, C., Sadoski, M., 2011. Do study strategies predict academic performance in medical school? Med. Educ. 45 (7), 696e703. Wolff, A.C., Ratner, P.A., 1999. Stress, social support, and sense of coherence. West. J. Nurs. Res. 21 (2), 182e197. Ying, Y.W., Lee, P.A., Tsai, J.L., Hung, Y., Lin, M., Wan, C.T., 2001. Asian American college students as model minorities: an examination of their overall competence. Cult. Divers. Ethn. Minority Psychol. 7 (1), 59e74. Zimmerman, B.J., Schunk, D.H., 2011. Self-regulated Learning and Performance. Taylor & Francis, New York, USA.
Please cite this article in press as: Salamonson, Y., et al., Sense of coherence, self-regulated learning and academic performance in first year nursing students: A cluster analysis approach, Nurse Education in Practice (2016), http://dx.doi.org/10.1016/j.nepr.2016.01.001