It is generally believed that the growth and development of a human being is greater in his first year of life than at any other time. Similarly, learning in a student nurse's experience is thought to be greater in her first clinical nursing course than at any other time in her nursing career. l She enters nursing, as it were, a "newborn" who must be told, "This is a hospital; this is a patient." She emerges, hopefully, a "toddler" taking her first independent steps, understanding more than she is able to practice and eager to further explore the world in which she has begun to have a part.
Unfortunately, over one-third of all the aspirants who enter schools of nursing never complete the curriculum; the largest number of these students leave sometime during the first clinical nursing course. 2 This high attrition rate represents a manifold loss to the public, to the health needs of the nation, to the profession, to the school, and, of course, to the student herself. Notwithstanding our rationalizations about students who withdraw from nursing as being "better off" in another field if they are not entirely committed to nursing, we must acknowledge the great financial and psychological cost to the student "in terms of lost time and effort and the personal disappointment and frustration arising out of an unsuccessful experience." 3
A great many studies have been done by individuals and by schools of the attrition rate phenomenon. Hill et al. reviewed over three hundred cases in an effort to discover a correlation between the causes of attrition from schools of nursing and the rate of job turnover in professional nursing. The reason for the high rate of attrition, both voluntary and involuntary, of nearly half the dropouts was "failure in classwork," and Hill et al. therefore concluded that "the means for eliminating a large percentage of the dropouts due to failure in course work are readily at hand through the use of tests." They feel that many schools do not adhere to a strict cut-off point, and that, if the schools did, 75 percent of this group of dropouts could be eliminated before admission; the rest would then apparently be the victims of the less than 100 percent validity of the tests. The second largest group of dropouts (30 percent) includes students whose reasons are classified as "marriage and/or dislike of nursing." The investigators must have felt that reasons in this category are too interdependent to be separated.
A great deal of effort is currently being expended by educators on the development and perfection of ingenious tests for predicting with reasonable accuracy the "desirable" and the "undesirable" students, i.e., the potentially successful and unsuccessful applicants to schools of nursing, so that the latter can be rejected when they apply. There are the usual aptitude, intelligence, personality, interest, and motivation tests. There are multiple choice, projection, and essay tests, and the newest, free-form sentence completion tests, by means of which the psyche of even the wisest test-taker can be coded and analyzed. It is conceivable that in the near future a marriagability test will be devised to predict who will deflect for this reason.
In spite of the most modern filtering processes and their diligent use by many schools, attrition rates in nursing education remain stable. Whatever the reasons and wherever the flaws, the fact remains that one-third of the candidates who desire to learn professional nursing never learn to be nurses. When they drop out, we assume that they have failed. It is less often assumed that perhaps in some way the school has failed. This paper purposes to examine the learning situation itself, some of the organic factors and attitudes which affect it, and the related shortcomings within the school that contribute to and produce failure in student nurses.
The beginning student in either a diploma or a baccalaureate program has all the problems of an older adolescent in addition to those of a student nurse. Dorothy Mereness, Dean of the School of Nursing of the University of Pennsylvania, says, 4
Many of us, however, expect students to skip the adjustment problems of late adolescence and emerge on the day they enter the school as mature fullfledged adults . . . Such terminology is a hopeful denial of the fact that we are actually carrying on the serious business of nursing sick people with the help of adolescents.
The student's main problem is to relinquish her dependency on her parents and to achieve maturity and emancipation in a new and often threatening environment. She may have chosen nursing partly to escape from her home environment only to find that she has entered a similar one, complete with personal restrictions, demanding female instructors and supervisors, and rival classmates instead of siblings. If her home adjustment was poor, patterns of behavior may carry over and prevent her from learning in the new environment. 4
Late adolescents are still anxious about acceptance by their peers. They enjoy identifying with a group, wearing a uniform, and having standards to lean upon in crises. They are also anxious about their physical appearance and unsure of their real personality. Both these factors are considered part of their total performance in nursing and are criticized as freely as is their technical proficiency. Since this situation occurs at a stage in life when the young "self" is so vulnerable, "the combination of disappointment, anguish, aggression, and fear with which she reacts becomes understandable." 4
Because of her age and inexperience in the "outside" world, the student nurse has an even greater need for love and approval than do the rest of us. She needs instructors who accept her as a learner, who can tolerate mistakes, and who can differentiate between discipline and punishment.5
The older adolescent is still blessed with a tremendous energy drive, expressed now as enthusiasm for a great variety of interests. Her creativeness allows her to see established routines from a fresh viewpoint, and she needs an educational environment in which she can feel free to experiment with new solutions to old problems.
Another major concern of the older adolescent is with sex and marriage. Studies of the career plans of student nurses show that less than 10 percent plan to make a career of nursing; the rest see themselves as future wives and mothers. What many of these students do not realize, and most of our schools are unlikely to point out to them, is that both roles are possible, and in many cases even desirable. The President's Commission on the Status of Women said, of women in general: 7
A growing feeling on their part that life in a child's world uses only part of their capabilities has over the past few years motivated more of them to keep alive their intellectual interests and increased the degree to which American society will have the benefit of all its human resources.
The inflexible, convent-like rules in many diploma schools of nursing promote the belief that the practice of nursing is not compatible with any other role: 8
Although it need not be, this problem is posed, time and time again, as one of choice - of being either a nurse or a wife and mother; and, of course, such a choice is not difficult to make for a young woman in a society such as ours.
And as is apparent from our attrition rate, it is a choice (nurse or wife and mother) made frequently by our first-year student nurses. Restrictions against marriage, particularly in the college programs are, however, slowly being lifted. One writer feels that "a little less masochistic sacrifice and a little more personal satisfaction" should be a goal of nursing education.9
The student nurse is, first of all, a biological organism whose potential for behavior change, or learning, is to a large extent governed by her physiological functioning. When the biological organism is malfunctioning, desirable changes in behavior may be inhibited and undesirable learning can occur.
Nurses are taught that the general well-being of all organisms is dependent upon adequate diet. Malnutrition often occurs in the older adolescent not because of lack of food but because of poor choice of food. Worry, fear, and preoccupation with problems can be deterrents to normal appetite. Malnutrition and lack of essential vitamins under experimental conditions have been shown to produce apathy, depression, irritability, nervousness, and marked personality changes ranging from mild hypochondria to psychosis. 10
Student nurses are no more knowledgeable about proper nutrition when they enter the school than are other older adolescents. This may be the first time a student is away from home and has the responsibility of choosing her food, usually cafeteria style. The first course in nutrition must have as one of its objectives the student's acceptance of the responsibility to keep her own body well nourished. A student nurse cannot effectively teach principles of health and nutrition if she does not believe in and practice them herself. Under the stress of new experiences, she can easily allow coffee and cigarettes to replace her daily bread. A student who has not been thoroughly persuaded of the inadvisability of this practice has not learned in this area, and will be prevented from attaining maximum learning in other areas.
Physical fatigue caused by a simple lack of sleep can retard learning and cause "failure." Realistic and cooperative planning by the faculty should make it possible to prevent the assignment of so much "busy work" that only the hardy students who can survive on a minimum of sleep are able to complete it satisfactorily. Many of our diploma schools still feel that every hour of the student's life while she is in the school is part of the curriculum, and that it is not only the responsibility but the duty of the faculty to see that it is spent profitably. Students who are away from home for the first time, however, are tempted to assert their new independence by burning the candle at both ends until they arrive at a scale of values. We should not encourage this practice further by considering a student deficient in socialization if she chooses to catch up on her sleep rather than play basketball, sing in the glee club, attend a student organization meeting, or help with the bake sale.
Fatigue has other than physical causes, and even the healthy student who really does get enough sleep frequently appears at the health service complaining that she is "always tired." Pressey enumerates several psychological causes, not all amenable to easy solution by the faculty, which should certainly be considered when a physically healthy student is constantly tired, e.g., unimaginative teaching, unpleasant surroundings (and what hospital can really be considered pleasant?), a tense atmosphere, distraction from more interesting outside activities (in this case, probably marriage), and other personal problems.1
Reider believes that the autocratic system in both nursing education and nursing administration plays a "pathogenic role" in preventing nurses from giving vent to their frustrations. The nurses therefore take out their hostilities on themselves; this, he believes, is 9
. . . one of the chief psychological factors responsible for the major complaint of nurses, chronic fatigue, which operates in conjunction with real external factors which undoubtedly exist.
Attitudes and Psychological Factors
Every applicant to a school of nursing is asked the question, "Why do you want to be a nurse?" More than 90 percent of these applicants say, in one way or another, "Because I want to help people." Many deep psychological reasons for this altruism have been postulated, but regardless of the reason, beginning nursing students are probably among the most idealistic and highly motivated groups with which any instructor has the privilege of dealing. One study indicated that much of this motivation originates in the mass media; a typical statement made by an entering student was "I had a glorious picture of not anything in particular -just helping sick people." 12 Many students, figuratively speaking, lighted their lamps in early childhood during a sickness or hospitalization, and some in adolescence when the feminine consciousness began to awaken. Some are in school against their parents' better judgment, having suffered as only the adolescent can suffer to win a battle of tears, threats, and endurance. The learner is ready, she is eager to begin, and she is willing to endure all known and unknown inconveniences in order to attain her goal. If she is a baccalaureate student, however, she may have a long wait before she ever sees a patient. The first course in "orientation to nursing" is likely to take at least one semester of her time orienting her to what nursing is and is not, dispelling all her "illusions" about the glamour of life in a hospital, and getting her ready to "interact" with patients. A good number of students will be "lost" during this period, either to another major (with the typical comment that "nursing is for the birds"), or to a diploma program where it is more likely that she will find out, firsthand, what nursing is and is not before she grows tired of waiting. One school, which rearranged its curriculum to provide clinical experience earlier in the program, found that its attrition rate dropped from 41 percent to 11 percent. 3
By ignoring and even actively trying to dispel the idealism of their students, many nurse educators are not recognizing that 13 u
. . . level of motivation is responsible for level of performance. In other words, higher motivation leads to more adequate performance if the latter leads to eventual satisfaction of the motive . . . strong positive motivation makes it possible to withstand and overcome stresses that otherwise threaten security.
As the student begins to adjust her vague, glamourized ideas of nursing to reality, it is the job of the instructor to substitute external incentives for the internal ones when necessary. Heidgerken has noted that much of the interest and enthusiasm which nursing students bring to the learning situation is lost by the junior year. She attributes the loss partly to poor teaching methods and insufficient study time, but principally to failure of the instructor to stimulate motivation by providing external incentives such as praise, reproof, and competition. 15
The drive for recognition or approval has been recognized as a powerful motivating force behind the actions of pupils. Dorothy Mereness points out that the student's ability to give "tender loving care" to her patients depends in large measure upon whether she has been given praise and love, since "human beings have a way of giving to the world what they themselves have received."
Reproof is most likely to become a problem of quality rather than quantity. The authoritarian, life-or-death atmosphere of a hospital spares no one when blame is to be meted out; the student, who is near the bottom of the totem pole, is likely to receive a generous share. The censure she may be subjected to comes from all directions: from instructors, service personnel, physicians, and the all-important patient, whose physical, emotional, spiritual, and social needs she is led to believe that she, in her immature wisdom, is to meet. Dr. Reider points out that it "takes a high degree of motivation and/or a high degree of masochistic absorption to withstand the indignities to which many students are subjected." 9 An important function of the nursing instructor, therefore, is to act as a buffer between the student and those who would have her perform as a skilled practitioner rather than as a learner, and to interpret her role to service personnel.
Some educators disagree with the use of competition in any form. They believe that the instructor should not evaluate the student according to the instructor's own knowledge, experience and judgment, but that the student should evaluate her own strengths and weaknesses in these areas and together with the instructor arrive at a mutually agreed upon grade. This system often requires that the student keep a "diary" of her clinical activities, including the inmost thoughts and feelings she has experienced. Having bared her soul on paper for the benefit of all instructors involved in the course, the student confers with them to bring all their new insight to bear upon the problem of deciding upon a grade. Is it any wonder that many students become "failures" in order to retreat to an educational setting where their conflicting emotions are accorded more privacy?
The role of emotion is a primary one in learning, although its exact function is debatable. When emotion is related to motivation to learn, it enhances desirable learning. But when the emotion or feeling becomes focal in its influence, the other features in the situation may go unnoticed, and the desired learning does not occur. The interrelationship of emotion, motivation, and punishment has been well described by Prescott: 16
Summarizing the punishment experiments, it may be said that punishment, administered during learning for mistakes made, has universally been found to increase the speed and efficiency of learning, providing it does not produce emotional reactions of more than a critical intensity. Affect beyond this intensity will inhibit further attempts at learning. It is conceivable that the amount of punishment that will be endured depends to a considerable extent upon the affective strength of the motivation.
Another reason the first clinical course in nursing is such a crucial one is that the "set," or attitude, toward problem solving which the student acquires is likely to carry over to similar situations in later courses. It may also be carried over to dissimilar situations where it will be a hindrance; in this case it is- called rigidity. Ideally, one should be able to acquire a set easily and get rid of it when it is no longer useful. Again, an interrelationship is present: "Students who are highly motivated, or tense or anxious are somewhat more likely to acquire a set than those who are indifferent or less anxious." 17 Another writer points out the importance of a "situational expectancy" for eventual success as an important factor in performance in a problem-solving situation. 18 Explanation of set in terms of prior experience is certainly consistent with tradition in the psychology of learning. The instructor responsible for choosing experiences for her student nurses must be as aware as possible of the student's prior experiences which are to be built upon. Students must not be allowed to become overwhelmed by lack of knowledge and understanding, by being placed in situations where the skill of a graduate professional nurse is expected and required. Feelings of frustration, inadequacy, and despair can produce emotional conflict, can inhibit learning, and can result in attrition from the course.
The nurse educator who faces a class of new student nurses in their first' clinical course has the responsibility of making successes, not failures, of them. She should regard each student as having the academic ability to pass her courses. Reasons for failure to learn should be sought diligently within the school, the curriculum, the instructor and her methods, and the student. There is no cause for pride in the large number of students one has "flunked out." Undoubtedly, some students will discover that they have made a mistaken choice of vocation; let us make certain the mistake is theirs, not ours.
- 1. M. E. Heinemann: "The Conflicting Life of a Student," Nursing Outlook, 12:35, 1964.
- 2. B. L. Tate: "Attrition Rates in Schools of Nursing," Nursing Research, 10:91, 1961.
- 3. L. HiU et aL: "Is There a Correlation Between Attrition in Nursing Schools and Job Turnover in Professional Nursing?" Nursing Outlook, 11:666, 1963.
- 4. D. Mereness: "Meeting the Student's Emotional Needs," American Journal of Nursing, 52:336, 1952.
- 5. C. Babcock: "Emotional Needs of Students," American Journal of Nursing, 49:168, 1949.
- 6. M. C. Vaillot: Commitment to Nursing, Philadelphia, J. B. Lippincott Co., 1962.
- 7. President's Commission on the Status of Women, American Women, Washington, 1963.
- 8. E. C. Hughes et al.: Twenty Thousand Nurses Tell Their Story, Philadelphia, J. B. Lippincott Co., 1958, p. 239.
- 9. N. Reider: "Human Needs and Nursing," Public Health Nursing, 42:392, 1950.
- 10. L. Shaffer, and E. Shoben: The Psychology of Adjustment, Boston, Houghton Mifflin Co., 1956.
- 11. S. L. Pressey et al.: Psychology inEducation, New York, Harper Brothers, 1959.
- 12. D. Major: "Career Planning of High -Ranking Senior Students," Nursing Research, 10:69, 1961.
- 13. J. Deese: 77ie Psychology of Learning, New York, McGraw-Hill Book Company, 1958, p. 148.
- 14. W. C. Menninger: "Opportunities in Nursing for a Satisfying Life," American Journal of Nursing, 48: 527, 1948.
- 15. L. Heidgerken: Teaching in Schools of Nursing, Philadelphia, J. B. Lippincott Co., 1946.
- 16. D. A. Prescott: Emotion and the Educative Process, Washington, American Council on Education, 1938, p. 169.
- 17. J. M. Stephens: Educational Psychology, New York, Holt, Rinehart, & Winston, 1956, p. 377.
- 18. B. Tyler: "Expectancy for Eventual Success as a Factor in Problem Solving Behavior," Readings in Educational Psychology, Chicago, Scott, Foresman, and Co., 1962.