Student nurse attrition: use of an exit-interview procedure to determine students' leaving reasons

Article

Student nurse attrition: use of an exit-interview procedure to determine students' leaving reasons Christine Glossop This study is part of a research programme at the University of Glamorgan aimed at reducing student nurse discontinuation. A number of methodological limitations in previous studies on attrition have been identified and are addressed in this study. A preliminary picture of attrition within this school is established and the validity of the data examined. The average attrition rate for the school over an 8-year period was 19%, which compares favourably with national rates. Data on students' leaving reasons were obtained through an exit-interview procedure; this achieved high response rates which for exceed those represented in previous studies. Academic difficulties and wrong career choice were among the most commonly reported leaving reasons; this is similar to findings from previous research. However family, health and financial difficulties emerge as equally important categories. The exit form facilitated the recording of multiple leaving reasons for each student, an innovative approach in attrition research. Almost half the students discontinued for at least two reasons; the interrelationships between leaving reasons and possible explanations for the findings are considered. The complexity of factors contributing to attrition are discussed and will be tackled in subsequent stages of the research programme. & 2002 Published by Elsevier Science Ltd

Introduction

Christine Glossop BSc, MSc, RGN, HV, Research Fellow, School of Care Sciences, University of Glamorgan, Pontypridd CF37 1DL, UK. Fax: ‡44(0) 1443 483140 Manuscript accepted: 7 November 2001

Student nurse attrition from pre-registration courses is assuming increasing importance, not only within nurse education but also in the wider context of mainstream higher education. The recent rise in attrition appears to be related to politically based issues of accountability within the public services (Glossop 2001). Many different groups of stakeholders have an interest in student nurse discontinuation. Political and financial implications are important for the Government both nationally (Lipley 2000) and in each of the principalities (National Assembly for Wales 2000, O'Dowd 2000). Concerns have been expressed by the

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statutory organizations for nursing such as the UKCC and the Scottish National Board (O'Dowd 2000), which need to ensure the suitability of courses for preparing people, often from a wide range of backgrounds, to become competent and confident nurses (UKCC 1999). The interests of nurses and students are represented by the Royal College of Nursing (1998), and the financial difficulties of some student nurses have recently received high-profile attention in the nursing press (Ryan 2000, Lipley 2000). Schools of nursing are concerned by attrition not only in terms of meeting targets and wastage of resources, but also with respect to

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the affects on staff morale (Council of Deans and Heads 1998). Trusts and nurse managers have a responsibility to maintain an adequate nursing work force, and enable qualified nurses and preceptors to provide supportive and good quality learning environments for students on their placements. Last, but most certainly not least, the discontinued students themselves may suffer considerable emotional, social and financial costs (McSherry & Marland 1999). The different interests of stakeholders may be reflected in different perspectives on the issue. The historical context of student nurse attrition and the changing perspectives towards the problem have been documented by Coakley (1997) and Glossop (2001). Over the last 20 years attrition rates have remained at around 15±20% (Coakley 1997, UKCC 1987). Significantly, the introduction of Project 2000 does not appear to have reduced attrition rates, despite this being one of the aims of the programme. Although considerable research has been conducted into attrition over the last two decades, both in the UK and around the world, the problem remains to be solved. The complexity of issues surrounding attrition and the difficulties of conducting rigorous research were highlighted in a recent review of the literature (Glossop 2001). A number of methodological limitations with previous research were identified. These included low response rates (in surveys of discontinued students) and difficulties with measurement, such as imprecise definitions of leaving reasons and lack of attention to the possible relationships between them. In addition, most studies were based on single centres; thus their findings could not be readily generalized to other schools of nursing. Conceptual issues included an over-emphasis on student characteristics at the expense of investigating influences such as school policies or socioeconomic factors. Although much research in the UK has concluded with recommendations concerning measures to reduce attrition, there is little documentation of whether these have been implemented and even less evidence of evaluation. However, the literature review, both in the UK and at the international level, did show some consistent findings: the predominant leaving reasons

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reported by students or schools were found to be academic failure, family or personal difficulties, and wrong career choice (Glossop 2001). The limitations of previous research illustrate the inherent difficulties in achieving a sound knowledge base, on which practical solutions for tackling the problem can be based. A staged, evaluative research programme, established in the School of Care Sciences at the University of Glamorgan in 1998, was aimed at reducing attrition of students from pre-registration nursing courses. The 3-year programme was designed to address the methodological limitations, using a combination of quantitative and qualitative methods. The critical investigation of the literature described above represented the first stage of the programme. The present study represents the second stage of the programme. It was aimed at establishing a preliminary picture of attrition at this school and examining the validity of the data, in the light of the methodological issues. The objectives of the study were to:  Explore possible trends in student nurse attrition rates at the University of Glamorgan  Establish baseline data on the reasons why students discontinued; identify and begin to explore interrelationships between leaving reasons  Address the problem of low response rates from discontinued students  Evaluate the current system used to collect information on leaving reasons  Use the preliminary findings as a basis from which the direction and plans for future stages of the research could be formulated  Extend the research to other schools of nursing in Wales.

Methods The project is being guided by a multidisciplinary project board, which has included the Head and Associate Heads of the School, Head of the School Research Unit, the National Assembly for Wales nursing representative, clinical and student representatives, lecturers and research staff.

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In this school, data on discontinued students have been routinely collected since 1992 and maintained on a spreadsheet. This include biographical information on all students and a summary of their reasons for leaving. For the purposes of the present study data from three different sources were collected and analysed. Firstly, registry statistics were used to determine attrition rates for each cohort over an 8-year period since the start of Project 2000 (between April 1992 and April 2000). Attrition was defined, according to requirements of the National Assembly for Wales, as the difference between the numbers of students beginning each cohort and the numbers who completed that cohort. Thus students who took a break from the course were included as discontinued students from the cohort they started with. Those who came back from a break were included in the statistics for the cohort to which they returned. Students who transferred to, or from, pre-registration nursing courses in other institutions were included in the statistics on a similar basis. The numbers of students who discontinued from each cohort over this period, the stage of the course at which they left, and the branch to which they were allocated were also calculated. Secondly, student files provided information on leaving reasons. Information on students who discontinued from early Project 2000 cohorts had been confined to documentation such as letters. Thus data on these students was very limited. For all cohorts from April 1996 a procedure was introduced, exclusively within this school, for routinely collecting information from students when they discontinued, whether for voluntary reasons or academic failure. This procedure is ongoing and enables the systematic collection of information on students' leaving reasons. The system was developed within the school as a tool for monitoring attrition, rather than as a research tool, and its' validity had not been assessed before the commencement of data collection. If students discontinue, they are invited to participate in an interview with their personal

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tutor, or a senior member of the School staff, to discuss the reasons influencing their decision. After the interview an exit form is completed by the member of staff who records all the reasons which, they consider, led to the student discontinuing. Each reason is rated on a scale of one to five, according to its importance as perceived by the tutor. Thus a reason of low importance is attributed a score of one, and one of high importance a score of five. Other reasons, or further information, can also be recorded on the form. Student-stated reasons can be recorded by the tutor, particularly if they are different from the tutor-stated reasons. For those students who did not take part in an interview a form was sometimes completed independently by the tutor, if they had some knowledge of the student's circumstances. In other cases, where an exit form had not been completed, information was obtained from the student's file or verbally from a senior member of staff. The present study included data on leaving reasons for students who discontinued from all cohorts between April 1996 and April 1999. All students who left up to September 1999 were included. Data were analysed according to the main and subsidiary leaving reasons for each student. If a student was reported to have just one reason for leaving, this was classed as the main reason. For students who had more than one reason recorded, the one with the highest score was designated as the main reason and the others classed as subsidiary reasons. To achieve uniformity in the data for the purposes of this study, it was decided to allocate one main reason to each student. A few students were recorded as having two reasons each with a score of five. In these cases further information on the exit form or other documents, such as letters in the student's file, were searched for related comments. On the basis of these comments the researcher judged which reason should be categorized as `main' and which was `subsidiary', and this was

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Results Trends in attrition rates The School of Care Sciences at University of Glamorgan admits two cohorts of pre-registration nursing students each

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year onto the diploma and degree courses. Over the duration of this study the majority of students were undertaking diploma courses and, for the present purposes, they are not distinguished from degree students. Over the total period included in the study (April 1992 to April 2000) each cohort comprised between 65 and 110 students, later intakes tending to have more students. The majority of students followed the adult branch and the remainder undertook the child, mental health or learning disabilities branches. Figure 1 shows the overall attrition rates from pre-registration courses over the eight cohorts from April 1992 to April 1997, the latter being the last completed cohort at the time of writing. The total number of students who discontinued was 179. The attrition rates fluctuated between 12% (October 1993) and 24% (April 1993). The average rate of attrition over this period was 19% (Table 1). Table 1 shows that a greater proportion of students discontinued from April cohorts (20%) than from October cohorts (17%), but this is not statistically significant (2 ˆ 0.9993, P > 5%). Figure 2 demonstrates, for the same cohorts, the stage of the course during which students most frequently discontinued. Students taking, or returning from, a break from the course were excluded. The majority of students (56%) left during the Common Foundation Programme (CFP), particularly during the first year. Nevertheless a substantial proportion (44%) left during the branch stage.

30 Attrition rate [%]

checked independently by a second researcher. Because this situation arose in only a very few cases, it was considered that the validity of the present findings would not be compromised. The majority of subsidiary reasons had been allocated scores of three or four. A very few had scores of one; these were considered relatively unimportant and were excluded from the analysis, to prevent distortion of the findings. The section on student-reported reasons was only completed for a few students and in most of these cases the student-stated reasons were similar to those stated by the tutor. In the very few cases where there were discrepancies, the tutor-stated reasons were used in order to be consistent. Some students took a temporary break from the course for 6 or 12 months, with the intention of returning, and were not included. Anecdotal evidence suggested that over the period of the study most of these students took a break for maternity reasons. The third source of data comprised informal discussions with school lecturers and current students. This has been ongoing since the commencement of the research project in order to obtain both staff and student perspectives. The discussions were used to explore the factors underlying reported leaving reasons and possible relationships between them. Information on changes in school policies and course organization, which might have contributed to attrition, was also obtained. Extending the study to other schools of nursing throughout Wales proved more difficult an undertaking. Collaboration was achieved with most of the schools in Wales during the initial stage of the research programme and work is still underway. However, resources were only available for a limited amount of data collection.

25 20 15 10 5 0 Apr-92

Apr-93

Apr-94 Apr-95 Cohort

Apr-96

Apr-97

Fig. 1 Attrition rates (April 92±April 97 cohorts).

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Table 1 Numbers of discontinued Students: April and October cohorts Cohort

Commencing (n)

Discontinued (n)

Attrition (%)

516 437 953

104 75 178

20 17 19

April (1992±97) October (1992±96) All cohorts (April 1992±April 1997) 2 ˆ 0.9993, P > 5%.

25

Number of students

120

80 60

20

15

10

5

20

0

m ily Ac ad em ic Fi na nc W ia ro l ng ca He al re th er C ch ha Low o ng ic at e ed te nd ci a rc n um c st e an ce M s at e N rn o/ i lim Pe ty ite rs on d in al fo rm at io n

40

Fa

Number of students

100

0 Common Foundation Programme Stage of course

Branch

Fig. 2 Stage of course during which students discontinued (cohorts: April 1992±1997, 172 discontinued students).

Leaving reason

Fig. 4 Main leaving reason reported (cohorts April 1996±1999; 105 discontinued students).

40

Percentage attrition

35 30 25 20 15 10 5 0 Adult

Child

Mental health

Learning disability

particularly high for the learning disabilities students (34%). This branch admits substantially fewer numbers of students than the adult or mental health branches. It is very striking that, for some cohorts, the proportion of students leaving the learning disabilities branches was so high that the actual numbers of these students were almost as great as the numbers leaving the much larger adult branch.

Branch

Fig. 3 Attrition of students by branch (cohorts April 1992±1997, total of 945 students commenced).

Figure 3 shows the differences in attrition rates between the four branches. Data are presented as percentage of discontinued students from each branch. Rates were lowest for the child branch (16%), followed by mental health (18%) and adult (19%). Rates were

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Reasons for attrition A total of 105 students discontinued from cohorts between April 1996 and April 1999, the time-period over which exit data were collected. This represents 16% of the total number of students who commenced the course over this period. The main leaving reasons are shown in Fig. 4. Family difficulties were the most commonly reported (17% of discontinued

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students). Academic difficulties (including exam or assignment failure), financial problems, ill health and wrong career choice were the next most frequently reported (approximately 11% each). Low attendance at school or placements was reported for 9% of students. Changed circumstances, reported for a few students (5%), usually referred to a course transfer, for example due to a partner's job move. No students had clinical difficulties reported as a main leaving reason. A substantial proportion of those students who discontinued (42%) had at least two leaving reasons reported; some students had three or four reasons each. A total of 165 reasons were recorded across all students, giving an average of 1.6 reasons per student. When both main and subsidiary reasons were combined for all students, the numbers of most types of reasons were substantially increased. Figure 5 shows the total number of main and subsidiary reasons. Family circumstances again assumed the most importance (24% of students). Academic reasons were the next most frequently reported (18%), followed by financial difficulties and wrong career choice (17% each). Ill health and low attendance (at the school or placements) were reported for 16% and 15% of students, respectively. Clinical and travelling difficulties emerged as new categories (8% and 5% of students, respectively).

Number of students

30 25 20 15 10 5 0

s s ty n e h e ic ly al el al mi dem anci hoic ealt danc ultie terni Trav ance rson atio H en t Pe orm a Fin er c fic Ma s f c i t f m d A t e n u l i r a c a d ir ca w ite gc Lo Clini dc on ge /lim Wr an No h C Leaving reason

Fa

Fig. 5 Main and subsidiary leaving reasons reported (cohorts April 1996±1999; 105 discontinued students).

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For 22% of students there was no, or very little, information. Typically these students had not appeared to seek help with any difficulties, and had decided to leave without discussing their situation with their personal tutor. In these cases, and also those who discontinued due to low attendance, tutors made repeated attempts to contact the student by letter and/or phone, usually without success. In addition, a few students failed to return from a break in training, and did not inform the School of their reasons.

Discussion Attrition rates Comparison of attrition rates between schools, or at the international level, has been constrained by the lack of a common definition of attrition (UKCC 1999) and by variations in the methods used to calculate attrition rates (Glossop 2001). However, in the present study the methods adopted to calculate rates were as required by the National Assembly for Wales (Welsh Office 1999) and the same as those used by the WNB (1997/8) and ENB (1995±1999). This school appears to have been relatively successful in retaining students. The attrition rate of 19% compares very favourably to the higher rates of 20% for Wales (WNB 1997/8) and 22% for England (ENB 1997/8). Within the branches, child (16%) and mental health (18%) fared a little better than the adult branch (19%). National figures (ENB 1996/7, 1997/8) show similar rates for the child and adult branches (18% each) but a higher rate for mental health (24%). There is only a little evidence from individual schools on variations between branches. In Swansea the adult branch fared better than other branches; fewer students discontinued from the adult than the mental health or child branches (White et al. 1999). The high rate of discontinuation of students from the learning disabilities branch (34%) is fairly consistent with national rates for this branch. For example in England, for cohorts completing in 1996 or 1997, 28% of students discontinued from learning disabilities branches (ENB 1995/6, 1997/8).

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No statistics for this branch were found from individual schools. Unlike England (ENB 2001), most schools in Wales do not provide a learning disabilities branch. Thus comparison of overall attrition rates within Wales might be more meaningful if this branch is excluded. When the numbers of students on the learning disabilities branch are excluded from the total numbers of students, the attrition rate drops to 18%, which now compares even more favourably to national statistics in Wales. The high discontinuation rates from the learning disabilities branch have, therefore, effectively inflated the overall rates at this school. Attrition rates from the learning disabilities branch have been a cause for concern at this school and the reasons have been further investigated. There are some apparent trends in discontinuation rates over time at this school. Peaks and troughs are evident between 1992 and 1994, but since 1995 the rates appear to have stabilized. It is possible that trends in attrition rates may reflect changes in school policies or course organization. There have been a few reports of the effects of such changes on student nurse discontinuation in other studies. For example, problems with course organization were reported by students as leaving reasons (White et al. 1999, Parker & Carlisle 1996). However, over most of the period of the present study there were relatively few changes at this school. Recently the school has undergone considerable change over a relatively short period of time. The school was transferred from a hospital to a university campus in 1997, although Project 2000 had been in place since 1992. In the same year, team teaching was changed to course modularization, which resulted in students being in contact with greater numbers of lecturers and perhaps experiencing more formal relationships with staff. The first BSc programme was also established in 1997. In addition, student portfolios and a new system to assess clinical competencies were introduced for cohorts from October 1997. Anonymous marking was established for the whole university in 1998. The introduction of a block system of placements in 1997 led to

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students being away from the university for long periods of time. These administrative changes have been considered by a number of lecturers to increase the demands placed on both students and staff, with possible negative influences on both. For example, a change in the tutorial role has been thought by some staff to have a detrimental effect on subsequent tutor±student relationships. Also it has been suggested that the onset of specialist teaching may have raised lecturers' expectations of students' academic performance. Since these changes occurred relatively recently, they are only applicable to ongoing cohorts and cannot be linked to the attrition figures presented in this study. Nevertheless, any attempts to correlate these events with later trends in attrition rates would be challenging. Because there have been so many changes within the school over a relatively short time-span, the combined effects of these on student experiences, and on subsequent attrition rates, would need to be unravelled. Furthermore, some changes are applicable to particular cohorts, while others affect all students present at the school at that time. Any new school policy, which is applicable to all students, would need to be evaluated on the basis of a definition of attrition that differs from that used in the present study, which focuses on cohorts. Attrition figures would have to relate to the total student population present at the school over a specific time-span before, and after, the introduction of the policy. The possible effects of changes within the school on the experiences of students, and on discontinuation, are being examined using qualitative methods during the third stage of the research programme. Concurrent research projects have also been undertaken at the school to specifically evaluate the introduction of the student portfolio (Dolan & Fairbairn 2001, Harris et al. 2001) and the new system to assess clinical competencies (Dolan 2001). While having some beneficial effects, these have both been found to increase the sense of pressure for some students. Aspects of the clinical competencies system have been of concern, for example they have been very time-consuming and students felt they had

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insufficient time to dedicate to the portfolio. In addition, evaluative research of clinical placements has been undertaken (Biddyr 2001).

At what stage of their course do students discontinue? Although most students discontinued during the CFP, a sizeable number (44%) left during the branch stage. The finding is not consistent with those of previous studies, which showed that attrition occurred predominantly during the first 18 months of the course (Braithwaite 1994, White et al. 1999, Worthington 2000). However, this should be seen in the context of the considerable variation that exists between schools in the assessment strategies they adopt (McSherry & Marland 1999). Also, it is possible that for students who discontinued during Branch, their difficulties may have arisen during CFP, but the formal decision to leave (whether made by the student or school) was finalized during the branch stage of the course. In addition, procedures for re-sits and appeals have sometimes been lengthy processes and, if instigated later in the CFP, may have been carried over into the branch stage. The school is addressing this issue.

Why do students leave? A complex agenda Family circumstances comprised the most prominent of main leaving reasons, being reported by almost a fifth of discontinued students. The next most common categories, ranked alongside each other, were academic and financial difficulties, ill health and wrong career choice. These findings differ notably from the emphasis of much previous research on attrition, both in the UK and abroad, which has focused on academic issues or cited them as the most common leaving reasons (Glossop 2001), while attributing less importance to family difficulties. Although health and financial problems were as common as academic difficulties in the present study, they have been far less evident in previous studies. The only similarity between this and previous studies is the

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prominence of wrong career choice as a leaving reason. When the data on main leaving reasons, are merged with the data on subsidiary reasons, a considerably expanded picture is revealed. For example, the proportion of students experiencing family difficulties rises to a quarter. Many of the factors assume much greater weight than when single main reasons are considered, and clinical and travel difficulties emerge as new categories. Otherwise, the distribution of categories remains similar to that for main reasons. Informal discussions with staff and students, as well as information in students' files, have revealed diverse views on possible relationships between leaving reasons. For example, financial difficulties may have encouraged some students to leave in order to follow a better-paid career, or could have led others to undertake part-time work. The latter in turn may have caused academic difficulties or non-attendance at the school or placements, due to the additional demands on the students' time and energy. Ill health could have had an impact on students' academic performance or attendance on the course, and so contributed to other leaving reasons. Alternatively, ill health may have been a consequence of stress which was precipitated by difficulties such as academic or financial problems. Financial difficulties were ranked among the five commonest leaving reasons. At the time of writing the financial situation of nursing students has received high-profile attention in the nursing press. It has been described as a significant problem for students, and recent surveys have found that up to 60% of students had considered leaving for financial reasons (Ryan 2000, Lipley 2000). However, these studies only focused on students in progress and did not include those who had actually discontinued. This has indeed been the case in most recent studies of attrition (Hughes 1998, Coakley 1999). The relatively high levels of ill health found in the present study, as both main and subsidiary reasons, have scarcely been reported in previous studies, with the exception of Richardson (1996). One

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explanation may be that students in poor health did not participate in the studies, and so contributed to the low response rates. Alternatively, given that levels of financial and family difficulties were also comparatively high, is it possible that wider socioeconomic factors may be operating? The University of Glamorgan is situated in the `Valleys' region of south Wales. Encompassed in the university's mission statement is a commitment to serve the communities in this region and widen access to students from backgrounds not traditionally associated with higher education. Furthermore, the School of Care Sciences has a particular remit to recruit students from this region, as required by NHS Wales and local trusts. The geographical mobility of the local population is very low and it is hard to recruit staff to the health service from outside the region. Thus the trusts rely on recruiting staff from the south Wales valleys, and during the selection of student nurses, priority is given to applicants who reside here. Many of the `Valleys' communities of South Wales experience marked socioeconomic deprivation (Welsh Office 1993). There is plenty of evidence to show the considerable impact that social disadvantage can have on the health and family well-being of communities (Acheson 1998). Students who come from these communities are thus more likely to experience health, financial or family difficulties than those from less disadvantaged communities. Furthermore, high levels of stress among student nurses have been demonstrated in previous research (Hamill 1995, Jones & Johnston 1997, Lindop 1999). Perhaps disadvantaged students are particularly vulnerable to stresses arising from their course, while their counterparts who come from more advantaged socioeconomic circumstances are better protected from the adverse consequences of stress. Preliminary investigation of the exit data in the present study revealed that most students who discontinued for health, financial or family reasons lived in localities characterized by high levels of socioeconomic deprivation. By comparing the localities of discontinued students with those of students in progress, it might be seen whether socioeconomic circumstances could be having

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an affect on attrition. These data are not yet available; it is hoped to investigate this question at a later stage in the research programme. There appears to be little previous research in the UK on the possible effects of socioeconomic factors on student nurse attrition. In South Africa, Mashaba and Mhlongo (1995) found differences between students in their experiences, depending on their socioeconomic circumstances; for example students from lower socioeconomic backgrounds suffered fear of rejection. In the UK the affects of socioeconomic disadvantage on achievement within mainstream higher education is a significant issue in the current political climate. Across all students there have been higher levels of discontinuation from the new universities than from the older, traditional universities (Higher Education Funding Council (HEFC) 1999), yet the new universities attract higher proportions of students from working class backgrounds (social classes 3, 4 and 5) than the old universities. The government is concerned to widen access to universities throughout the UK by reaching communities not traditionally associated with participating in higher education. For example, HEFC provides grants to encourage universities to increase take-up of students from areas where university participation rates are lower than average (Woodward 2001).

Has this study succeeded in addressing the methodological issues? The introduction of an exit interview procedure to monitor students' leaving reasons resulted in great improvements in the quantity and quality of information being collected, not only within this school, but also compared to previous research studies. Information was obtained for 78% of discontinued students. By research standards, this represents a very satisfactory response rate and far exceeds the rates reported in previous studies. The procedure, through use of a structured exit form, enabled the collection of data on students' leaving reasons. The form also enabled the recording of data on all possible reasons for each student and thus, as a research

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measure, had adequate content validity. The success of a structured system aimed at monitoring attrition has therefore been demonstrated, which utilizes personal tutors or senior lecturing personnel. This study has begun to address the complexity of factors contributing to attrition. Almost half of the students were reported as having at least two leaving reasons, demonstrating that it is inappropriate to reduce a student's circumstances to one main reason. There might be a cluster of related reasons for each student, which contribute in some way to their discontinuation. This would be masked by the use of research measures that only allow for the reporting of one reason for each student, as used in previous studies (Woolley 1989, Jalili-Grenier 1993, Braithwaite et al. 1994, Richardson 1996, Ehrenfeld et al. 1997, Mashaba et al. 1995, Al-Kandari & Ajao 1998, White et al. 1999). However, other limitations of previous research have persisted into the present study. The definitions of leaving reasons are similar to those used in previous research and remain imprecise. They have not been sufficiently sensitive to clarify the specific nature of students' difficulties (McSherry & Marland 1999). For example, we do not know to what extent academic difficulties could be attributed to exam or assignment failure, difficulties with particular modules, or lack of study skills. For those students who fail what are the specific reasons for failure? This is being investigated in the next stage of the present research programme through the use of qualitative interview methods with both students and staff. Despite the good response rates, a proportion of students continued to slip through the net, despite valiant attempts by tutors to contact them. Furthermore, some of the students who had low attendance reported as a leaving reason were similarly elusive. Little is known about why students were poor attenders; the reasons might have been any one of a number of categories, for example poor health, family problems, or the need to undertake paid work due to financial difficulties. Low attendance was one of the more frequently cited categories (main reason for 9% students). Personal circumstances

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(main reason for 1% students) comprise another vaguely worded category. If both these categories are combined with that of little or no information, the proportion of students on whom there is no, or limited, information rises to 30%. This represents a substantial number of students who discontinued without discussing their situation in full with their tutor. Also, it is likely that they did not use available resources to help them manage their difficulties. In the next study such elusive students have been targeted in order to further increase the response rates and obtain more valid data on students' leaving reasons. The present study, as indeed do most studies, has focused on discontinued students, rather than those still in progress. It is quite possible that continuing students also experience family, financial, health or even academic difficulties to some degree. If both these groups of students experience similar levels of difficulties, what are the factors that enable some to continue while others drop out? With the exception of White et al. (1999) there is little evidence from previous research of comparison between the two types of students. This issue has been addressed in the present research programme and students in progress have been compared with those who have discontinued. The findings will be reported at a later date. Data were not collected on students who took a temporary break from the course, except for those who did not return who were included as discontinued students. The reasons why students take a break, and the contribution made to attrition by those students who do not return, could usefully be examined in future research. However, one confounding factor is the Department of Social Security regulation which stipulates that nursing students on a break are not entitled to receive benefits, although their bursary is suspended. Thus they are left in a position of considerable financial disadvantage. It is possible that students who wished to take a temporary break from the course, but could not afford to do so, decided to register as discontinued although they planned to return. The school has recently addressed this issue and all

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students who wish to take a break from the course are now required to de-register from the course and re-register when they return.

Conclusion This school has been relatively successful at retaining pre-registration nursing students when compared with other schools. This has been particularly the case for mental health branch students, but not for those from the learning disabilities branch. Family circumstances were the most frequently reported leaving reasons. The relatively high levels of these along with ill health and financial difficulties, compared to findings from previous research, might be explained by the impact of socioeconomic circumstances on students' abilities to complete the course. Alternatively the low response rates in previous studies may have concealed similar levels of difficulties among non-participating discontinued students. This study has demonstrated that some of the methodological limitations in investigating the factors contributing to attrition can be successfully tackled. The use of exit-interview procedures to collect information on discontinued students enabled good response rates to be achieved, which were much higher than those reported in previous studies. The exit form, developed as a tool for audit of students' leaving reasons, has been shown to be a useful research measure for the collection of preliminary data; a particular strength has been the recording of multiple leaving reasons. The findings have indicated the complexity of factors which can contribute to attrition, suggesting that previous research has been too simplistic in reducing a student's circumstances to just one leaving reason. Ongoing research within this school is addressing further methodological issues and will be reported on at a later date. Qualitative studies are identifying the perceptions of lecturers and examining factors within the school which might contribute to attrition. The experiences of discontinued and continuing students are being explored in order to compare the two groups, achieve

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more precise definitions of leaving reasons and unravel interrelationships between them. Findings from these studies are informing recommendations for measures to reduce attrition and also the establishment of a relational database; this will facilitate ongoing monitoring of attrition and further interventions as appropriate. The challenge of reducing student nurse attrition in the UK remains. Around one-fifth of students discontinue from their courses, often for reasons which are complex, unclear or unknown. Ongoing research within this school will hopefully provide data which are more comprehensive and valid than have yet been obtained. If such data can inform the planning and evaluation of interventions to retain more students, then schools of nursing, trusts, students and the public purse can only benefit. Acknowledgements

Many people in the School of Care Sciences in the University of Glamorgan have contributed to the work reported in this paper. Members of the School Attrition Group established the system for monitoring attrition and devised the exit form. Professor Donna Mead, Head of the School and Associate Heads, Dr Barbara Bale and Mr Andrew Rogers, have given ongoing support. Staff in the Admissions Office assisted with data extraction and Melanie Evans, research associate, contributed to the data analysis. The Research project was established by Professor Mead and Professor Colin Torrance and more recently supervised by Professor Laurie Moseley. Drafts of this article have been read and commented on by Professor Moseley, Dr Robert Williams and Mr Andrew Rogers. References Acheson ED 1998 Independent inquiry into inequalities in health: report. HMSO, London Al-Kandari FH, Ajao E 1998 Recruitment and retention of nursing students in Kuwait. International Journal of Nursing Studies 35: 245±251 Biddyr S 2001 Creating a learning environment in the clinical arena. Proceedings of Annual Nursing Research Conference, RCN, Glasgow

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