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Student discontinuations: is the system failing?
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Student discontinuations: is the system failing? Wilfred McSherry and Glenn R. Marland Are nurse educators guilty of hypocrisy? While espousing holism and evidence-based practice, we may be neglecting to support the most distressed and vulnerable in our care – students . Student discontinuation arouses strong emotions, which need to be expressed and resolved. These are often unresolved leaving students and educators frustrated and alienated in ‘failure’. Although it cannot be expected that all students will succeed as professionals and academic standards must be maintained, those who fail have a right to expect fairness. With the advent of Subject Quality Review (formally TQA) institutions of higher education may be asked to demonstrate their operational mechanisms for ‘managing’ the process of student failure. Now would be the best time for departments of nurse education to reflect on experience, review attrition rates and learn from each other in order to establish a model of best practice. Such a review may generate the formulation of national guidelines, safe guarding against the looming threat of litigation. © 1999 Harcourt Publishers Ltd
An analogy Wilfred McSherry RGN, BSc (Hons), PGCE (FE), RNT, MPhil, Lecturer in Adult Nursing Studies, Department of Health Studies, The University of York, York District Hospital, Wigginton Road, York YO3 7HE, UK. Tel.: 01904-453996 Glenn R. Marland RMN, Bed (Hons) Dip, N. MN RNT, Course Coordinator Mental Health Nursing, Dumfries Campus, Bell College of Technology, Crichton Hall, Glencaple Road, Dumfries DG1 4SG, UK. Tel.: 01387244063 (Requests for offprints to WMS) Manuscript accepted: 10 March 1999
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Metaphorically nurse education is the ‘Grand National’. All horses and riders strive to complete the gruelling course, some horses, (students), fall at the first hurdle others at the last. Educators and assessors are trainers guiding students around the course, educationally and clinically, getting them into shape for the challenges imposed by the hurdles (Assessments). The owners (patients, taxpayers and the nursing profession) have made an investment; they will eventually win or lose depending upon how many of their horses stay the course. If the race is too tough or the horses entered too weak, and the horses and jockeys (personal lecturers) are inadequately trained or supported then the profession and public will have a shortage; a large number of horses not crossing the winning post. The aim is to have a highly trained horse ready to meet the challenge of nursing in the next millennium.
Introduction High attrition rates are now a perennial concern in nurse education (Dinsdale 1998). There are harrowing accounts from student nurses experiencing considerable distress upon
Nurse Education Today (1999) 19, 578–585
discontinuation (McGimsey 1988) often after grappling with personal problems and financial hardship (Anonymous 1994). It is congruent with notions of a ‘caring profession’ that students should be treated individually, and fairly. Inevitably not all learners will complete their course of study. The entire area of discontinuation, however, becomes contentious if criteria for failure are not equitable. Interestingly, SQR scores are published on the Internet. Candidates may look at a prospective department’s SQR score as a decisive measure when applying for nurse training. Student support and student progression may be the first subjects studied.
Aims of the paper • Discuss factors associated with fairness and equity in relation to student discontinuation • Demonstrate how student discontinuation is an integral part of Subject Quality Review This manuscript formed the basis for a theme presentation at the NET 98 Conference under the theme section Quality Issues & Contracting for Education.
© 1999 Harcourt Publishers Ltd
Student discontinuations: is the system failing?
• Discuss how academic and professional standards have become fragmented. • Present ‘A way forward’, which may ease some of the problems, associated with discontinuation.
Attrition rates The English National Boards (ENB) Annual Reports from 1993 to 1996, showing recruitment and wastage statistics for pre-registration nurse training, suggest attrition rates may be levelling out with totals of 17% for 2 years up to 1996 then with an encouraging dip to 15%. This average figure includes all branches; there is a range from 14% to 24%. These trends in attrition are a 50% increase upon ‘Pre-project 2000’ intakes, being almost as high as those reported before the inception of the National Health Service (Cross & Hall 1954). The National Audit Office (1992) reported wastage rates, for traditional courses, between 5% and 5.7% for the years 1986–1992. It is ironic that the Project 2000 initiative had reduction in wastage as a primary aim (UKCC 1989). In some institutions figures as high as 49% are documented (Dinsdale 1998). These approaches of publicly highlighting individual institutions, within nursing journals, however, are unhelpful in that they perpetuate the sense of secrecy and fear and are a form of scapegoating for a widespread problem (Dinsdale 1998). Attrition figures are subjective and depend upon a number of variables, for example the data collection/recording methods may not be sensitive enough; therefore, reasons documented for discontinuation may not be truly representative of the underlying cause. Also data is not collected consistently by different organizations. Referring back to the ENB statistics it would appear that the upward trend in attrition has abated; this does not mean that there is scope
for complacency. Academic failure includes both theory and practice. This is important as nurses, and other professional bodies, have argued for several years now that practice accrues academic credit (Simosko, 1991). This need to achieve in theory and practice has been referred to as the ‘double jeopardy’ in that to succeed academically a student nurse must pass the theoretical components and satisfy practice competencies (Marland & McSherry 1997). Discontinuation for either theoretical or practice failure brings into question levels of theoretical and clinical support, especially if students are discontinuing from a cohort in large numbers on personal or academic grounds. However, because of the inconsistencies in recording reasons for attrition it may be difficult to establish the real reason for leaving. Ameliorative measures are needed to reduce wastage. It is not expected that solutions to prevent discontinuations will be found speedily, it is being suggested that individual institutions liaising with professional bodies identify a strategy to help reduce student wastage (Coakley 1997). Another variable that must be considered in the attrition equation is the part that NHS Trusts have to play in reducing attrition for, example by ensuring that students and assessors receive appropriate clinical and educational (insights into the assessment process) support while students are in clinical practice. This brings into question issues around the role of link teachers in providing support and working in collaboration with managers, staff in NHS Trusts.
Action There is a need for: • A reliable and sensitive national system to record and monitor reasons for and levels of discontinuation
Excerpts taken from students’ letters who replied to a request for information (Marland and McSherry, 1997) are used, with the student’s written consent to illustrate themes throughout the paper which is written from the standpoint of student advocate. The views expressed in this article are not based on a systematic research methodology. The student quotations are used only as illustrations and are not necessarily representative of the wide body of student nurses. It is argued, however, that the preliminary anecdotal evidence presented in this article point to the compelling need for a thorough research based investigation. The problems identified do not necessarily relate to the authors’ own places of work, or indeed any other single institution. The main argument is not that particular providers of nurse education are at fault but that standards and approaches are inconsistent between institutions.
© 1999 Harcourt Publishers Ltd
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Student discontinuations: is the system failing?
• Collaboration between institutions in addressing attrition rates so that best practice can be identified and shared • Other variables to be included in the equation: mitigating circumstance, financial support, lowering of entry criteria (NVQ level III) which the authors feel may lead to a greater need for academic/pastoral support. However, it must be stated that at present there is no evidence to support or substantiate this claim.
‘failure’ poor self-esteem and a shattering of dreams as illustrated by the following extract;
Students and discontinuation
Lecturers and assessors of practice may also feel a sense of remorse and guilt because the student was unsuccessful (Turkett 1989, Symanski 1991). Colleagues of discontinued students are often left demoralized and feeling vulnerable. Lecturers may feel regret and bitterness towards the system, especially when students perform consistently well throughout the course and fall at the last hurdle. The cost of educating one nurse is in the region of £30 000 (Newton 1996). The economic ramifications of students and qualified nurses leaving the profession effect the taxpayer and the economy of the country. How much longer can the profession tolerate such high levels of wastage? However, one cannot ignore the other side of the debate that is the cost of retaining an inappropriate student? Both these factors have serious implications upon the image of nursing.
Reasons provided by students for discontinuation may not reflect the main underlying cause. A possible explanation for this lack of validity is that the student still needs to consider other career options, a major factor in seeking employment is a departmental reference. Students may be diplomatic with their reason(s) for discontinuation not wanting to be seen as highly critical or weak which may be reiterated in their character reference. Therefore, there is pressure on students to adopt a passive approach irrespective of whether they have been discontinued as a result of ‘failure’ through ‘personal reasons’. If student discontinuation is to be monitored effectively then the information recorded upon discontinuation sheets or during exit interviews needs to be authenticated. Arbitrary tick boxes such as, ‘Domestic reasons’ or ‘Wrong career choice’ or ‘other’ is neither specific nor sensitive enough. A student may find it expedient to identify with one or more of these reasons for leaving. It is harder to indicate causes which may point to a fundamental flaw in the way a course or specific module or assessment is being initiated or a lack of student support.
The cost of failure The cost of student failure must be viewed in its ‘totality’ having regard for the student, their peers, educationalists and practitioners and bearing in mind the larger economic ramifications. When a student is discontinued, for whatever reason, there can be a great deal of anger, frustration and resentment between all the parties involved (Turkett 1987, Castledine 1995). The cost to the student may be a feeling of
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Nurse Education Today (1999) 19, 578–585
‘I was referred to a Therapeutic Community where I spent 8 months talking of a lot of things not surprisingly a lot of it focused on my sense of loss of my nursing course. As you wrote in your article (Marland and McSherry 1997) of ‘nursing becoming a central part of the student’s personal identity & sense of self, that basically sums up the problems I had leaving’.
The image of nursing The problem is cyclical, prospective candidates may hear ‘horror’ stories from previous students who have discontinued or from nurses who have left the profession feeling exhausted and abused. This reverberates throughout society to the detriment of the profession’s image and ultimately to the public who experience the shortfall in skilled nursing staff. Potential solutions may be found by identifying ‘authentic’ reasons for student discontinuation. Such insights will enable the profession to start to eradicate the negative image, which it presents to the general public.
Support Dreams and ambitions can be shattered when a student is discontinued the student nurse may
© 1999 Harcourt Publishers Ltd
Student discontinuations: is the system failing?
well have internalized a self-image which relies on the occupational status of ‘nurse’ (Du Gay 1997). Students experiencing problems either theoretically or in practice should be identified early so that remedial interventions can be implemented. If there are doubts as to the suitability of a student for practice then the matter should be addressed speedily. It is neither morally, ethically or economically viable to allow students to be discontinued at their last assessment. In this event the rest of the student body feel threatened and become disillusioned. The following student comment reinforces the points that have been made: Perhaps the amelioration you discuss should kick-in at the earliest recognition that a student is in trouble so that an alternative future may be considered? Support for students who are experiencing difficulty theoretically or in practice can be provided through a variety of channels. Link Lecturer visits, extra personal tutorials or referral to counselling services. Historically establishments of nurse education have been housed within National Health Service hospitals. Geographically, these establishments are often at a distance from the main university campus. Students and staff can feel detached, isolated and not fully integrated within the university ethos. In an attempt to ease the transition of Departments of Nursing Integration Workers have been appointed to ensure awareness of the wider context of the university. The integration worker liaises with the student body, identifying student concerns relaying these to the students union and welfare officers in an attempt to provide access to the universities support networks.
Selection A candidate can gain entry into nurse education based on a variety of qualifications. These range from DC Test to Higher degrees. The potential need for support may be related to type of qualification on entry. By identifying prospective students’ perceived levels of support at interview, tentative measures to promote retention can be initiated. Caution must be exercised in using existing level of qualifications as an indicator of potential. For example, candidates who have achieved science-based
© 1999 Harcourt Publishers Ltd
Box 1
Stages in the discontinuation process
I.
Department Identifies and discusses reason for discontinuation with student II. Referral to the Universities Support Services III. Guidance provided re future career options after discontinuation IV. Accreditation for what has been undertaken academically and professionally
degrees may require support in relation to academic essay writing. Likewize candidates who have vocationally based qualifications may require additional theoretical support. The assessment of students’ abilities must be ongoing as weaknesses may only emerge through assessment in theory or practice, despite prior achievement (Thompson 1991). Houltram (1996) investigating the achievement of students in the Common Foundation Programme found that mature students (defined as age 22 +) performed above average and that students aged 17–21 (without conventional entry requirements) performed the most poorly of any group.
Support after discontinuation Students who discontinue themselves may decline any offer of support or assistance. Students who have been discontinued on either theoretical or practice grounds may feel devastated. It would appear that in some institutions a student upon discontinuation will usually be offered an exit interview and several weeks of bursary (a practice which may need to be justified to the funding agents?) and perhaps referred to the universities welfare services to access careers advice and counselling. Therefore, the current process of discontinuation typically operates around a series of identifiable stages (Box 1). The following excerpt demonstrates what impact the ‘human touch’ can have upon a student who discontinued on personal grounds. The most helpful part was being sent a letter from the Director of Nursing, she wished me well in my therapy and hoped that I would be fit enough to continue one day – that letter meant a lot – it’s a bit coffee stained now but I’ll probably keep hold of that one. A shoulder to lean on and an attentive listening ear at this time can prove very beneficial (O’Rourke 1988).
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Student discontinuations: is the system failing?
The authors feel that some departments may not perceive discontinued students as their responsibility? Therefore, isolating the failed student from channels of support when they are in most need. Nurse education has a moral obligation to provide some form of support to students who have been discontinued. The excerpt presented earlier shows how much a single letter from the head of a department comforted and reassured a student who had discontinued. By showing compassion and developing these pastoral aspects, the profession may be in a better position to offer some degree of guidance. It should not just be a case of giving the student an exit interview tapping them on their shoulder and saying ‘I’m sorry’. Students should be afforded the opportunity of further support, if they feel this necessary. This may be coordinated between the department of nursing and the universities’ welfare services. The benefits of receiving such support may go some way towards enabling adjustment to loss, rebuilding of damaged self-esteem and the reestablishment of control (Turkett 1987). The amount of support required does not need to be prolonged but of a sufficient duration to enable readjustment to begin. A type of resettlement programme that will enable the student to evaluate future career options. Yet one cannot escape the fact that this will require financing. However, most universities do have a welfare and careers service that students can access upon discontinuation. The emotional burden placed on educationalists (Symanski 1991) may also be lightened if they are assured that students are only discontinued fairly and with adequate support.
Fairness Parity and equity are important issues, which need to be addressed within the student discontinuation debate. Parity meaning there is some measure of equality and continuity between institutions in the manner in which students are discontinued on theoretical or practice grounds. By equity we mean fairness, and impartiality, should a student discontinue for what ever reason and at what ever stage in their training then they should have the same rights and treatment irrespective of institution. This means
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that students should have access to similar types and levels of support. Surely the issues of parity and fairness should be addressed or reviewed by regional education and training consortia who award the contracts to institutions. Should the consortia not be reviewing and ensuring standards are equitable between institutions? The assessment process in some institutions means that students must pass everything on the first or second attempt or risk being discontinued or running the gauntlet of appeal. In other institutions students are allowed to ‘carry’ or be ‘compensated’ for one failed assignment or practice placement, relieving the student’s personal tutor’s, and indeed assessor’s anxieties about failure. This point also indicates that there is a need for all involved in the educational process (lecturers, assessors and even students) to come to terms with the seriousness of their role. This ‘flexible’ approach may also reduce the amount of students who are discontinued on theoretical or practice grounds towards the end of their course. Its effects on the maintenance of professional standards have not been reported. The UKCC register is not closed to individuals applying for entry on to part 1, after following a part 12 course. Some students after failing academically, but successfully completing their practice outcomes are supported in attempts to enter part 1 of the register. This facility must be available to all students who have not reached the criteria to be awarded a diploma but who still may be eligible for registration onto part 1 of the UKCC register. Referring back to the analogy all horses start the course from the same point. Some of them may have been trained differently having a variety of different race (life experience) and academic experiences. Thompson (1991), however, suggests that retention relates more to student experience during their nursing course than pre-college achievements. Parity and fairness means all face hurdles or assessments of the same height. Methods of assessment may well be diverse, differing from one institution to the next; therefore, all horses are not running the same race. These disparities need to be addressed otherwize students have the potential to be failed in one institution in circumstances, which would pass in another. This has serious implications for the credibility of the assessment process and nursing.
© 1999 Harcourt Publishers Ltd
Student discontinuations: is the system failing?
Fragmentation of academic and professional standards The authors having talked to colleagues working in institutions throughout the UK would argue that academic and professional standards are at risk of becoming systematically fragmented. This fragmentation becomes apparent when a student appeals against discontinuation. When recommending discontinuation the Board of Examiners strives to consider both academic and professional issues but the Appeals Committee, which may not include a nurse, may focus only on academic issues. The rationale behind the decision of the Appeals Committee is not always shared with the Board of Examiners. Again the process of managing appeals and the relationship between Board of Examiners and Appeals Committees varies between institutions. The following example may illustrate a potential dilemma. If an educationalist or assessor feels that a student should not progress because of a professional concern identified in practice, or in the practice element of an assignment, examination, the Senate or Appeals Committee may not consider this matter in detail, looking only at the students academic record and achievements. The result may be that a student’s appeal is upheld giving them the opportunity to repeat a particular assignment thereby fragmenting the appeal process. Some Appeals Committees are departmentally convened while the Senate convenes others. The end of training declaration indicating a student’s fitness for practice is ultimately signed by a nurse educationalist. This is a source of concern to the authors since students may be allowed to succeed in academic terms that are known to be weak in practice. Students who are discontinued have a right to fairness and consistency. Appeals Panels should be transparent in their decision-making just as in the ‘Grand National’ race stewards are expected to be open and accountable. The effects that this process and its variations may have on the fairness of student failure need to be considered in a national review.
Subject Quality Review Subject Quality Review is a form of selfassessment exploring all aspects of the ‘total
© 1999 Harcourt Publishers Ltd
student experience’ across the continuum from admission to induction and course completion. Two important areas are assessed, contributing to the overall SQR score, which are applicable to this paper: student progression and achievement and student support and guidance (QAA 1997). Arguably you cannot have a good outcome in one section without this affecting the other. The main ethos of SQR is for an institution to identify perceived strengths and weaknesses setting its own agenda for the review process. This agenda is then inspected and reviewed by the SQR team. Documentation outlining all aspects of the students’ progression from one part of a course to the next or from one semester to the next will be traced. High attrition rates or lack of student progression may indicate to the reviewers that there is a problem at a particular stage in the course. High attrition rates may also reflect poor standards. A low attrition rate may be viewed more favourably in that it suggests there is good progression and student achievement. Documentation detailing departmental attrition rates and ameliorative measures implemented, if appropriate, may be subject to review. Implications are that departments of nurse education will need a systematic way of recording attrition that is sensitive at differentiating between such things as failure, withdrawal and transfers (all variables in the attrition equation). This may also bring under scrutiny all aspects of student support and guidance: tutorial attendance, documentation, feedback from examinations and assignments, external marker comments and actions taken. In this context SQR could be deemed as a student ally since it will encourage departments to review current methods of recording attrition rates, facilitating an analysis and problem resolution. It is important that SQR is not perceived as a witch-hunt but as a positive step in improving all aspects of the total student experience from induction to completion. SQR may also require departments to examine the support and welfare provision available to discontinued students. This process may force departments of nurse education to seek out areas of best practice reducing the amount of disparity that exists throughout the different regions of the UK.
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Student discontinuations: is the system failing?
Box 2
A proposed framework for the systematic assessment and evaluation of student discontinuation
Assessment • There is a need for continuos monitoring of attrition rates both locally and nationally. • Governing bodies to establish a national system for monitoring student attrition rates and reasons for student discontinuation. • Retrospective analysis of reasons for discontinuation by an independent audit team.
Planning • Establish national guidelines as to how attrition is to be monitored and recorded. Identify a member of staff who is responsible for student support – post discontinuation counselling.
Evaluation • Identify how frequently attrition rates are to be published.
Implementation • Produce standards highlighting what actions need to be undertaken when a student discontinues to ensure parity and equity between institutions. • Institutes national guidelines for Welfare Officers that will assist in determining future career choices open to students who discontinue.
• Ensure attrition rates are circulated so trends can be established, i.e. yearly • Identify areas of good practice so that institutions can exchange ideas and models of support
A way forward
Conclusion
It is proposed that in the medium term:
It would appear that nurse education is ‘failing those who fail’ in many facets of the total student experience. This brings into question notions of quality specifically when considering equity, parity fairness and integrity. It has been implied that SQR may help to confer order and uniformity between departments and institutions. The debate does generate aims worth pursuing. One student commented:
• Researchers who are independent from the institution providing nursing courses should conduct national and local reviews of attrition and its causes using a retrospective longitudinal analysis. It is proposed that in the short term: • Pre-exit counselling should provide support and identify reasons for discontinuation. • A systematic approach similar to the ‘nursing process’ is considered to provide some structure to the monitoring of student discontinuations (Box 2). • Guidelines be formulated explaining in detail what credits a student may be awarded by a department upon discontinuation taking into account both academic and professional achievements. This may provide welfare officers with useful information when planning future career options. • The structure of Appeals Committees and their relationship to Boards of Examiners is reviewed with integration of academic and professional standards as an imperative. • A graded bursary reflective of the increasing input of learners to clinical practice be considered which may enable students to qualify without significant debt be awarded (Williams 1998).
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It’s encouraging to think that nurses in your position are looking to help those who fail. I wish you well in your future research. Student discontinuation and reasons for attrition should not remain in the realm of speculation or be solely under the jurisdiction of Deans and Directors. All nurse educationalists have a responsibility to be aware of the cost of student failure (individually, departmentally and economically) and only then will they be able to help those who fail. Collaboration between institutions may enable nurse education to reverse the worrying trend of student discontinuation by sharing examples of good practice. Collaboration will also ensure that all students face the same hurdles and water jumps and run the same race, ensuring equity and fairness, thereby reducing the threat of litigation. The nursing profession may then begin to shake off its
© 1999 Harcourt Publishers Ltd
Student discontinuations: is the system failing?
pessimistic veil replacing it with one of optimism for the next millennium. References Anonymous 1994 What price charity. Nursing Times 90 (26): 71 Castledine G. 1995 Student nurses must be supported. British Journal of Nursing 4 (16): 964 Coakley L A 1997 Nurse education: attrition rates in the UK. Nursing Standard 11 (48): 45–47 Cross K W, Hall L A 1954 Survey of entrants to nurse training schools and student nurse wastage in the Birmingham region. British Journal of Preventative and Social Medicine 8: 70–76 Dinsdale P 1998 News analysis. Nursing Standard 12 (31): 14 Du Gay P 1997 Production of culture: cultures of production. Sage Publications, London English National Board 1993–1997 English National Board Annual Report. Houltram B 1996 Entry age, entry mode and academic performance on Project 2000 Common Foundation programme. Journal of Advanced Nursing 23: 1089–1097
© 1999 Harcourt Publishers Ltd
Marland G, McSherry W 1997 Do we fail those who fail? Nursing Times 93 (38): 61–62 McGimpsey J 1988 Why me? Nursing Times 84 (43):34 National Audit Office 1992 Nursing education: implementation of Project 2000 in England. HMSO, London Newton G 1996 Taking up nursing. Nursing Standard 11 (2): 16 O’Rourke M 1988 A shoulder to lean on. Nursing Times 84 (27): 48–49 QAA 1997 Subject Review Handbook October 1998 to September 2000 Ref No QAA1/97 Quality Assurance Agency for Higher education Simosko S 1991 APL a practical guide for professionals. Kogan Page Limited, London Symanski M E, 1991 Reducing the effect of faculty demoralization when failing students. Nurse Educator 16 (3): 18–22 Thompson D 1991 Graded versus pass/fail evaluation for clinical courses. Nursing and Health Care 12 (9): 480–482 Turkett S, 1987 Lets take the “I” out of failure. Journal of Nurse Education 26 (6): 246–247 Williams L 1998 Smooth the path into nursing. Nursing Standard 12 (46): 16
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Student discontinuations: is the system failing? Wilfred McSherry and Glenn R. Marland Are nurse educators guilty of hypocrisy? While espousing holism and evidence-based practice, we may be neglecting to support the most distressed and vulnerable in our care – students . Student discontinuation arouses strong emotions, which need to be expressed and resolved. These are often unresolved leaving students and educators frustrated and alienated in ‘failure’. Although it cannot be expected that all students will succeed as professionals and academic standards must be maintained, those who fail have a right to expect fairness. With the advent of Subject Quality Review (formally TQA) institutions of higher education may be asked to demonstrate their operational mechanisms for ‘managing’ the process of student failure. Now would be the best time for departments of nurse education to reflect on experience, review attrition rates and learn from each other in order to establish a model of best practice. Such a review may generate the formulation of national guidelines, safe guarding against the looming threat of litigation. © 1999 Harcourt Publishers Ltd
An analogy Wilfred McSherry RGN, BSc (Hons), PGCE (FE), RNT, MPhil, Lecturer in Adult Nursing Studies, Department of Health Studies, The University of York, York District Hospital, Wigginton Road, York YO3 7HE, UK. Tel.: 01904-453996 Glenn R. Marland RMN, Bed (Hons) Dip, N. MN RNT, Course Coordinator Mental Health Nursing, Dumfries Campus, Bell College of Technology, Crichton Hall, Glencaple Road, Dumfries DG1 4SG, UK. Tel.: 01387244063 (Requests for offprints to WMS) Manuscript accepted: 10 March 1999
578
Metaphorically nurse education is the ‘Grand National’. All horses and riders strive to complete the gruelling course, some horses, (students), fall at the first hurdle others at the last. Educators and assessors are trainers guiding students around the course, educationally and clinically, getting them into shape for the challenges imposed by the hurdles (Assessments). The owners (patients, taxpayers and the nursing profession) have made an investment; they will eventually win or lose depending upon how many of their horses stay the course. If the race is too tough or the horses entered too weak, and the horses and jockeys (personal lecturers) are inadequately trained or supported then the profession and public will have a shortage; a large number of horses not crossing the winning post. The aim is to have a highly trained horse ready to meet the challenge of nursing in the next millennium.
Introduction High attrition rates are now a perennial concern in nurse education (Dinsdale 1998). There are harrowing accounts from student nurses experiencing considerable distress upon
Nurse Education Today (1999) 19, 578–585
discontinuation (McGimsey 1988) often after grappling with personal problems and financial hardship (Anonymous 1994). It is congruent with notions of a ‘caring profession’ that students should be treated individually, and fairly. Inevitably not all learners will complete their course of study. The entire area of discontinuation, however, becomes contentious if criteria for failure are not equitable. Interestingly, SQR scores are published on the Internet. Candidates may look at a prospective department’s SQR score as a decisive measure when applying for nurse training. Student support and student progression may be the first subjects studied.
Aims of the paper • Discuss factors associated with fairness and equity in relation to student discontinuation • Demonstrate how student discontinuation is an integral part of Subject Quality Review This manuscript formed the basis for a theme presentation at the NET 98 Conference under the theme section Quality Issues & Contracting for Education.
© 1999 Harcourt Publishers Ltd
Student discontinuations: is the system failing?
• Discuss how academic and professional standards have become fragmented. • Present ‘A way forward’, which may ease some of the problems, associated with discontinuation.
Attrition rates The English National Boards (ENB) Annual Reports from 1993 to 1996, showing recruitment and wastage statistics for pre-registration nurse training, suggest attrition rates may be levelling out with totals of 17% for 2 years up to 1996 then with an encouraging dip to 15%. This average figure includes all branches; there is a range from 14% to 24%. These trends in attrition are a 50% increase upon ‘Pre-project 2000’ intakes, being almost as high as those reported before the inception of the National Health Service (Cross & Hall 1954). The National Audit Office (1992) reported wastage rates, for traditional courses, between 5% and 5.7% for the years 1986–1992. It is ironic that the Project 2000 initiative had reduction in wastage as a primary aim (UKCC 1989). In some institutions figures as high as 49% are documented (Dinsdale 1998). These approaches of publicly highlighting individual institutions, within nursing journals, however, are unhelpful in that they perpetuate the sense of secrecy and fear and are a form of scapegoating for a widespread problem (Dinsdale 1998). Attrition figures are subjective and depend upon a number of variables, for example the data collection/recording methods may not be sensitive enough; therefore, reasons documented for discontinuation may not be truly representative of the underlying cause. Also data is not collected consistently by different organizations. Referring back to the ENB statistics it would appear that the upward trend in attrition has abated; this does not mean that there is scope
for complacency. Academic failure includes both theory and practice. This is important as nurses, and other professional bodies, have argued for several years now that practice accrues academic credit (Simosko, 1991). This need to achieve in theory and practice has been referred to as the ‘double jeopardy’ in that to succeed academically a student nurse must pass the theoretical components and satisfy practice competencies (Marland & McSherry 1997). Discontinuation for either theoretical or practice failure brings into question levels of theoretical and clinical support, especially if students are discontinuing from a cohort in large numbers on personal or academic grounds. However, because of the inconsistencies in recording reasons for attrition it may be difficult to establish the real reason for leaving. Ameliorative measures are needed to reduce wastage. It is not expected that solutions to prevent discontinuations will be found speedily, it is being suggested that individual institutions liaising with professional bodies identify a strategy to help reduce student wastage (Coakley 1997). Another variable that must be considered in the attrition equation is the part that NHS Trusts have to play in reducing attrition for, example by ensuring that students and assessors receive appropriate clinical and educational (insights into the assessment process) support while students are in clinical practice. This brings into question issues around the role of link teachers in providing support and working in collaboration with managers, staff in NHS Trusts.
Action There is a need for: • A reliable and sensitive national system to record and monitor reasons for and levels of discontinuation
Excerpts taken from students’ letters who replied to a request for information (Marland and McSherry, 1997) are used, with the student’s written consent to illustrate themes throughout the paper which is written from the standpoint of student advocate. The views expressed in this article are not based on a systematic research methodology. The student quotations are used only as illustrations and are not necessarily representative of the wide body of student nurses. It is argued, however, that the preliminary anecdotal evidence presented in this article point to the compelling need for a thorough research based investigation. The problems identified do not necessarily relate to the authors’ own places of work, or indeed any other single institution. The main argument is not that particular providers of nurse education are at fault but that standards and approaches are inconsistent between institutions.
© 1999 Harcourt Publishers Ltd
Nurse Education Today (1999) 19, 578–585 579
Student discontinuations: is the system failing?
• Collaboration between institutions in addressing attrition rates so that best practice can be identified and shared • Other variables to be included in the equation: mitigating circumstance, financial support, lowering of entry criteria (NVQ level III) which the authors feel may lead to a greater need for academic/pastoral support. However, it must be stated that at present there is no evidence to support or substantiate this claim.
‘failure’ poor self-esteem and a shattering of dreams as illustrated by the following extract;
Students and discontinuation
Lecturers and assessors of practice may also feel a sense of remorse and guilt because the student was unsuccessful (Turkett 1989, Symanski 1991). Colleagues of discontinued students are often left demoralized and feeling vulnerable. Lecturers may feel regret and bitterness towards the system, especially when students perform consistently well throughout the course and fall at the last hurdle. The cost of educating one nurse is in the region of £30 000 (Newton 1996). The economic ramifications of students and qualified nurses leaving the profession effect the taxpayer and the economy of the country. How much longer can the profession tolerate such high levels of wastage? However, one cannot ignore the other side of the debate that is the cost of retaining an inappropriate student? Both these factors have serious implications upon the image of nursing.
Reasons provided by students for discontinuation may not reflect the main underlying cause. A possible explanation for this lack of validity is that the student still needs to consider other career options, a major factor in seeking employment is a departmental reference. Students may be diplomatic with their reason(s) for discontinuation not wanting to be seen as highly critical or weak which may be reiterated in their character reference. Therefore, there is pressure on students to adopt a passive approach irrespective of whether they have been discontinued as a result of ‘failure’ through ‘personal reasons’. If student discontinuation is to be monitored effectively then the information recorded upon discontinuation sheets or during exit interviews needs to be authenticated. Arbitrary tick boxes such as, ‘Domestic reasons’ or ‘Wrong career choice’ or ‘other’ is neither specific nor sensitive enough. A student may find it expedient to identify with one or more of these reasons for leaving. It is harder to indicate causes which may point to a fundamental flaw in the way a course or specific module or assessment is being initiated or a lack of student support.
The cost of failure The cost of student failure must be viewed in its ‘totality’ having regard for the student, their peers, educationalists and practitioners and bearing in mind the larger economic ramifications. When a student is discontinued, for whatever reason, there can be a great deal of anger, frustration and resentment between all the parties involved (Turkett 1987, Castledine 1995). The cost to the student may be a feeling of
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‘I was referred to a Therapeutic Community where I spent 8 months talking of a lot of things not surprisingly a lot of it focused on my sense of loss of my nursing course. As you wrote in your article (Marland and McSherry 1997) of ‘nursing becoming a central part of the student’s personal identity & sense of self, that basically sums up the problems I had leaving’.
The image of nursing The problem is cyclical, prospective candidates may hear ‘horror’ stories from previous students who have discontinued or from nurses who have left the profession feeling exhausted and abused. This reverberates throughout society to the detriment of the profession’s image and ultimately to the public who experience the shortfall in skilled nursing staff. Potential solutions may be found by identifying ‘authentic’ reasons for student discontinuation. Such insights will enable the profession to start to eradicate the negative image, which it presents to the general public.
Support Dreams and ambitions can be shattered when a student is discontinued the student nurse may
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well have internalized a self-image which relies on the occupational status of ‘nurse’ (Du Gay 1997). Students experiencing problems either theoretically or in practice should be identified early so that remedial interventions can be implemented. If there are doubts as to the suitability of a student for practice then the matter should be addressed speedily. It is neither morally, ethically or economically viable to allow students to be discontinued at their last assessment. In this event the rest of the student body feel threatened and become disillusioned. The following student comment reinforces the points that have been made: Perhaps the amelioration you discuss should kick-in at the earliest recognition that a student is in trouble so that an alternative future may be considered? Support for students who are experiencing difficulty theoretically or in practice can be provided through a variety of channels. Link Lecturer visits, extra personal tutorials or referral to counselling services. Historically establishments of nurse education have been housed within National Health Service hospitals. Geographically, these establishments are often at a distance from the main university campus. Students and staff can feel detached, isolated and not fully integrated within the university ethos. In an attempt to ease the transition of Departments of Nursing Integration Workers have been appointed to ensure awareness of the wider context of the university. The integration worker liaises with the student body, identifying student concerns relaying these to the students union and welfare officers in an attempt to provide access to the universities support networks.
Selection A candidate can gain entry into nurse education based on a variety of qualifications. These range from DC Test to Higher degrees. The potential need for support may be related to type of qualification on entry. By identifying prospective students’ perceived levels of support at interview, tentative measures to promote retention can be initiated. Caution must be exercised in using existing level of qualifications as an indicator of potential. For example, candidates who have achieved science-based
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Box 1
Stages in the discontinuation process
I.
Department Identifies and discusses reason for discontinuation with student II. Referral to the Universities Support Services III. Guidance provided re future career options after discontinuation IV. Accreditation for what has been undertaken academically and professionally
degrees may require support in relation to academic essay writing. Likewize candidates who have vocationally based qualifications may require additional theoretical support. The assessment of students’ abilities must be ongoing as weaknesses may only emerge through assessment in theory or practice, despite prior achievement (Thompson 1991). Houltram (1996) investigating the achievement of students in the Common Foundation Programme found that mature students (defined as age 22 +) performed above average and that students aged 17–21 (without conventional entry requirements) performed the most poorly of any group.
Support after discontinuation Students who discontinue themselves may decline any offer of support or assistance. Students who have been discontinued on either theoretical or practice grounds may feel devastated. It would appear that in some institutions a student upon discontinuation will usually be offered an exit interview and several weeks of bursary (a practice which may need to be justified to the funding agents?) and perhaps referred to the universities welfare services to access careers advice and counselling. Therefore, the current process of discontinuation typically operates around a series of identifiable stages (Box 1). The following excerpt demonstrates what impact the ‘human touch’ can have upon a student who discontinued on personal grounds. The most helpful part was being sent a letter from the Director of Nursing, she wished me well in my therapy and hoped that I would be fit enough to continue one day – that letter meant a lot – it’s a bit coffee stained now but I’ll probably keep hold of that one. A shoulder to lean on and an attentive listening ear at this time can prove very beneficial (O’Rourke 1988).
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The authors feel that some departments may not perceive discontinued students as their responsibility? Therefore, isolating the failed student from channels of support when they are in most need. Nurse education has a moral obligation to provide some form of support to students who have been discontinued. The excerpt presented earlier shows how much a single letter from the head of a department comforted and reassured a student who had discontinued. By showing compassion and developing these pastoral aspects, the profession may be in a better position to offer some degree of guidance. It should not just be a case of giving the student an exit interview tapping them on their shoulder and saying ‘I’m sorry’. Students should be afforded the opportunity of further support, if they feel this necessary. This may be coordinated between the department of nursing and the universities’ welfare services. The benefits of receiving such support may go some way towards enabling adjustment to loss, rebuilding of damaged self-esteem and the reestablishment of control (Turkett 1987). The amount of support required does not need to be prolonged but of a sufficient duration to enable readjustment to begin. A type of resettlement programme that will enable the student to evaluate future career options. Yet one cannot escape the fact that this will require financing. However, most universities do have a welfare and careers service that students can access upon discontinuation. The emotional burden placed on educationalists (Symanski 1991) may also be lightened if they are assured that students are only discontinued fairly and with adequate support.
Fairness Parity and equity are important issues, which need to be addressed within the student discontinuation debate. Parity meaning there is some measure of equality and continuity between institutions in the manner in which students are discontinued on theoretical or practice grounds. By equity we mean fairness, and impartiality, should a student discontinue for what ever reason and at what ever stage in their training then they should have the same rights and treatment irrespective of institution. This means
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that students should have access to similar types and levels of support. Surely the issues of parity and fairness should be addressed or reviewed by regional education and training consortia who award the contracts to institutions. Should the consortia not be reviewing and ensuring standards are equitable between institutions? The assessment process in some institutions means that students must pass everything on the first or second attempt or risk being discontinued or running the gauntlet of appeal. In other institutions students are allowed to ‘carry’ or be ‘compensated’ for one failed assignment or practice placement, relieving the student’s personal tutor’s, and indeed assessor’s anxieties about failure. This point also indicates that there is a need for all involved in the educational process (lecturers, assessors and even students) to come to terms with the seriousness of their role. This ‘flexible’ approach may also reduce the amount of students who are discontinued on theoretical or practice grounds towards the end of their course. Its effects on the maintenance of professional standards have not been reported. The UKCC register is not closed to individuals applying for entry on to part 1, after following a part 12 course. Some students after failing academically, but successfully completing their practice outcomes are supported in attempts to enter part 1 of the register. This facility must be available to all students who have not reached the criteria to be awarded a diploma but who still may be eligible for registration onto part 1 of the UKCC register. Referring back to the analogy all horses start the course from the same point. Some of them may have been trained differently having a variety of different race (life experience) and academic experiences. Thompson (1991), however, suggests that retention relates more to student experience during their nursing course than pre-college achievements. Parity and fairness means all face hurdles or assessments of the same height. Methods of assessment may well be diverse, differing from one institution to the next; therefore, all horses are not running the same race. These disparities need to be addressed otherwize students have the potential to be failed in one institution in circumstances, which would pass in another. This has serious implications for the credibility of the assessment process and nursing.
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Fragmentation of academic and professional standards The authors having talked to colleagues working in institutions throughout the UK would argue that academic and professional standards are at risk of becoming systematically fragmented. This fragmentation becomes apparent when a student appeals against discontinuation. When recommending discontinuation the Board of Examiners strives to consider both academic and professional issues but the Appeals Committee, which may not include a nurse, may focus only on academic issues. The rationale behind the decision of the Appeals Committee is not always shared with the Board of Examiners. Again the process of managing appeals and the relationship between Board of Examiners and Appeals Committees varies between institutions. The following example may illustrate a potential dilemma. If an educationalist or assessor feels that a student should not progress because of a professional concern identified in practice, or in the practice element of an assignment, examination, the Senate or Appeals Committee may not consider this matter in detail, looking only at the students academic record and achievements. The result may be that a student’s appeal is upheld giving them the opportunity to repeat a particular assignment thereby fragmenting the appeal process. Some Appeals Committees are departmentally convened while the Senate convenes others. The end of training declaration indicating a student’s fitness for practice is ultimately signed by a nurse educationalist. This is a source of concern to the authors since students may be allowed to succeed in academic terms that are known to be weak in practice. Students who are discontinued have a right to fairness and consistency. Appeals Panels should be transparent in their decision-making just as in the ‘Grand National’ race stewards are expected to be open and accountable. The effects that this process and its variations may have on the fairness of student failure need to be considered in a national review.
Subject Quality Review Subject Quality Review is a form of selfassessment exploring all aspects of the ‘total
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student experience’ across the continuum from admission to induction and course completion. Two important areas are assessed, contributing to the overall SQR score, which are applicable to this paper: student progression and achievement and student support and guidance (QAA 1997). Arguably you cannot have a good outcome in one section without this affecting the other. The main ethos of SQR is for an institution to identify perceived strengths and weaknesses setting its own agenda for the review process. This agenda is then inspected and reviewed by the SQR team. Documentation outlining all aspects of the students’ progression from one part of a course to the next or from one semester to the next will be traced. High attrition rates or lack of student progression may indicate to the reviewers that there is a problem at a particular stage in the course. High attrition rates may also reflect poor standards. A low attrition rate may be viewed more favourably in that it suggests there is good progression and student achievement. Documentation detailing departmental attrition rates and ameliorative measures implemented, if appropriate, may be subject to review. Implications are that departments of nurse education will need a systematic way of recording attrition that is sensitive at differentiating between such things as failure, withdrawal and transfers (all variables in the attrition equation). This may also bring under scrutiny all aspects of student support and guidance: tutorial attendance, documentation, feedback from examinations and assignments, external marker comments and actions taken. In this context SQR could be deemed as a student ally since it will encourage departments to review current methods of recording attrition rates, facilitating an analysis and problem resolution. It is important that SQR is not perceived as a witch-hunt but as a positive step in improving all aspects of the total student experience from induction to completion. SQR may also require departments to examine the support and welfare provision available to discontinued students. This process may force departments of nurse education to seek out areas of best practice reducing the amount of disparity that exists throughout the different regions of the UK.
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Box 2
A proposed framework for the systematic assessment and evaluation of student discontinuation
Assessment • There is a need for continuos monitoring of attrition rates both locally and nationally. • Governing bodies to establish a national system for monitoring student attrition rates and reasons for student discontinuation. • Retrospective analysis of reasons for discontinuation by an independent audit team.
Planning • Establish national guidelines as to how attrition is to be monitored and recorded. Identify a member of staff who is responsible for student support – post discontinuation counselling.
Evaluation • Identify how frequently attrition rates are to be published.
Implementation • Produce standards highlighting what actions need to be undertaken when a student discontinues to ensure parity and equity between institutions. • Institutes national guidelines for Welfare Officers that will assist in determining future career choices open to students who discontinue.
• Ensure attrition rates are circulated so trends can be established, i.e. yearly • Identify areas of good practice so that institutions can exchange ideas and models of support
A way forward
Conclusion
It is proposed that in the medium term:
It would appear that nurse education is ‘failing those who fail’ in many facets of the total student experience. This brings into question notions of quality specifically when considering equity, parity fairness and integrity. It has been implied that SQR may help to confer order and uniformity between departments and institutions. The debate does generate aims worth pursuing. One student commented:
• Researchers who are independent from the institution providing nursing courses should conduct national and local reviews of attrition and its causes using a retrospective longitudinal analysis. It is proposed that in the short term: • Pre-exit counselling should provide support and identify reasons for discontinuation. • A systematic approach similar to the ‘nursing process’ is considered to provide some structure to the monitoring of student discontinuations (Box 2). • Guidelines be formulated explaining in detail what credits a student may be awarded by a department upon discontinuation taking into account both academic and professional achievements. This may provide welfare officers with useful information when planning future career options. • The structure of Appeals Committees and their relationship to Boards of Examiners is reviewed with integration of academic and professional standards as an imperative. • A graded bursary reflective of the increasing input of learners to clinical practice be considered which may enable students to qualify without significant debt be awarded (Williams 1998).
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It’s encouraging to think that nurses in your position are looking to help those who fail. I wish you well in your future research. Student discontinuation and reasons for attrition should not remain in the realm of speculation or be solely under the jurisdiction of Deans and Directors. All nurse educationalists have a responsibility to be aware of the cost of student failure (individually, departmentally and economically) and only then will they be able to help those who fail. Collaboration between institutions may enable nurse education to reverse the worrying trend of student discontinuation by sharing examples of good practice. Collaboration will also ensure that all students face the same hurdles and water jumps and run the same race, ensuring equity and fairness, thereby reducing the threat of litigation. The nursing profession may then begin to shake off its
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pessimistic veil replacing it with one of optimism for the next millennium. References Anonymous 1994 What price charity. Nursing Times 90 (26): 71 Castledine G. 1995 Student nurses must be supported. British Journal of Nursing 4 (16): 964 Coakley L A 1997 Nurse education: attrition rates in the UK. Nursing Standard 11 (48): 45–47 Cross K W, Hall L A 1954 Survey of entrants to nurse training schools and student nurse wastage in the Birmingham region. British Journal of Preventative and Social Medicine 8: 70–76 Dinsdale P 1998 News analysis. Nursing Standard 12 (31): 14 Du Gay P 1997 Production of culture: cultures of production. Sage Publications, London English National Board 1993–1997 English National Board Annual Report. Houltram B 1996 Entry age, entry mode and academic performance on Project 2000 Common Foundation programme. Journal of Advanced Nursing 23: 1089–1097
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Marland G, McSherry W 1997 Do we fail those who fail? Nursing Times 93 (38): 61–62 McGimpsey J 1988 Why me? Nursing Times 84 (43):34 National Audit Office 1992 Nursing education: implementation of Project 2000 in England. HMSO, London Newton G 1996 Taking up nursing. Nursing Standard 11 (2): 16 O’Rourke M 1988 A shoulder to lean on. Nursing Times 84 (27): 48–49 QAA 1997 Subject Review Handbook October 1998 to September 2000 Ref No QAA1/97 Quality Assurance Agency for Higher education Simosko S 1991 APL a practical guide for professionals. Kogan Page Limited, London Symanski M E, 1991 Reducing the effect of faculty demoralization when failing students. Nurse Educator 16 (3): 18–22 Thompson D 1991 Graded versus pass/fail evaluation for clinical courses. Nursing and Health Care 12 (9): 480–482 Turkett S, 1987 Lets take the “I” out of failure. Journal of Nurse Education 26 (6): 246–247 Williams L 1998 Smooth the path into nursing. Nursing Standard 12 (46): 16
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