Dr. Hadenfeldt is Assistant Professor, Creighton University School of Nursing–Hastings Campus, Hastings, Nebraska.
The author has no financial or proprietary interest in the materials presented herein.
The author thanks Dr. Lois Linden and Dr. Patricia Morin, College of Saint Mary; Dr. Joan Norris, Creighton University School of Nursing; and Dr. Deborah Brennan, Central Community College, for their assistance with the dissertation and manuscript.
Address correspondence to Cynthia J. Hadenfeldt, EdD, RN, Assistant Professor, Creighton University School of Nursing–Hastings Campus, 715 North Saint Joseph Avenue, Hastings, NE 68901; e-mail: CynthiaHadenfeldt@Creighton.edu.
Undergraduate nursing student success in program completion and on the National Council of Licensure Examinations (NCLEX®) involves a complex process that cannot be predicted by one or two variables and cannot be achieved without academic ability and persistence by students, along with effective nursing program resources (Fraher, Belsky, Carpenter, & Gaul, 2008; Jeffreys, 2004; Seago & Spetz, 2003; Shelton, 2003). Lack of success in coursework can prevent students from completing the program. A faculty-developed intervention plan was implemented for a 2-year period for students at risk for coursework failure due to academic, attendance, or behavioral reasons in one multicampus community college setting. Comparisons of success outcomes were made with comparable years (i.e., the 2 years preceding the use of the plan, similar sample size, same type of students [PNs and ADNs] who completed the same coursework in their respective programs) prior to the intervention. The specific aims of this retrospective study were to determine whether:
- The intervention plans made a difference in the practical nursing (PN) and associate degree nursing (ADN) student outcomes related to course and program completion. NCLEX success rates were also compared for PN and ADN graduates of years with and without the intervention plans.
- Student demographic characteristics (e.g., gender, age) affected the achievement of student outcomes over the two time periods (i.e., the years with the intervention and the 2 years prior to implementation of the intervention plan).
- A difference in student success between students who received a single intervention plan and those who received intervention plans for two or more courses was noted.
- The reason for the plan (failing to meet academic, behavioral, or attendance requirements) affected the likelihood of student success.
The conceptual model that was used to organize the literature review and guide the study was adapted from a model developed by Fraher et al. (2008) in a study of Associate Degree Nursing Program Success at the University of North Carolina (Figure). The model displays characteristics of students who enter a nursing program, nursing program characteristics necessary for success, and potential student outcomes.
Figure. Conceptual model of nursing student success. Adapted from Fraher, Belsky, Carpenter, and Gaul (2008).
The ability to achieve success in college coursework and complete a nursing program may be influenced by student characteristics, as well as nursing program characteristics. The student characteristics include demographics (age, gender, ethnicity); the student’s specific goals and determination to achieve them; the student’s educational background and academic ability, family responsibilities, external support system availability; and adequate financial resources (Fraher et al., 2008; Gardner, 2005; Jeffreys, 2004; Shelton, 2003). Nursing program characteristics include admissions policies, faculty qualifications, faculty instructional strategies and support, and academic and social support services. These characteristics may determine whether the student meets the demands and rigors of the program and achieves success or withdraws from the program.
Age as a predictor of nursing student success has resulted in contrasting findings in the literature. It is assumed that younger or traditional students are better able to focus on educational pursuits with fewer interruptions, have study skills developed from high school experiences, and are less encumbered with family and employment responsibilities that make finding time to study difficult (Jeffreys, 2004; Shelton, 2003). However, traditional students were found to have less success in coursework than older or nontraditional students in several studies (Fraher et al., 2008; Mulholland, Anionwu, Atkins, Tappern, & Franks, 2008; Pryjmachuk, Easton, & Littlewood, 2008). Nontraditional students may have obstacles to overcome to achieve success, such as needing to relearn study skills, increased hours of employment, and family responsibilities. Jeffreys (2004) cautioned against assuming that traditional or nontraditional students are “homogenous groups.” Both traditional and nontraditional students may be motivated to learn and provide the best financial picture for their future (i.e., career success, financial security), but both may have family and work responsibilities and struggle with study skills and time management (Fraher et al., 2008; Jeffreys, 2004; Shelton, 2003).
Male and ethnic minority students enroll in nursing programs in lesser numbers with increased rates of attrition (Gardner, 2005; Jeffreys, 2004; Mulholland et al., 2008; Pryjmachuk et al., 2008; Stickney, 2008). The stereotypical image of nurses as females deters some men from entering the ranks of nursing (Jeffreys, 2004). In the study by Gardner (2005), ethnic and racial minority students faced obstacles while pursuing nursing education. Families did not understand the students’ aspirations and were uncooperative about sharing family and financial responsibilities to allow the students time to study. Ethnic students also felt alone in their pursuits, with fellow students being indifferent to them and faculty not realizing the language barriers and stresses they were experiencing at home (Gardner, 2005).
The students’ goal determination and the degree to which they have attained success in prior educational experiences affects persistence through difficult nursing coursework (Jeffreys, 2004; Shelton, 2003). Goal determination may be lessened by limited seating in the nursing program if the student is delayed for admission for months or years due to waiting lists of qualified applicants (Seago & Spetz, 2003). Family members’ educational background may increase the student’s goal determination if family members understand the challenges of higher education and are able to offer emotional and financial support (Jeffreys, 2004). Once enrolled in the program, completion of difficult coursework requires determination to persist or students may withdraw from the program.
Family responsibilities and external support sources affect students’ ability to be successful (Gardner, 2005; Jeffreys, 2004; Shelton, 2003). Home maintenance, care for dependent children, necessary purchases, food preparation, and bill payment require regular attention and may not be compatible with academic requirements. If employment responsibilities are added to the load, students may feel overwhelmed with the many demands for their time and energy. An unexpected family crisis (i.e., illness, death, divorce) can affect school attendance and student academic achievement (Jeffreys, 2004; Shelton, 2003). External support sources can make the difference between withdrawing from the program and continued success. Support can come from family, who assist the students by assuming responsibilities in the home, providing child care or transportation, or assisting financially (Jeffreys, 2004; Shelton, 2003), or from classmates in peer study groups who can help students master course content and prepare for examinations.
Financial resources are a predictor of student success, as students bear the cost of college and household expenses and may be required by employers to maintain a workload of 20 or more hours per week to retain their jobs and health insurance. In a study on attrition rates in California community college nursing programs, Seago and Spetz (2003) found that the main reason students withdrew from nursing programs was financial (having to maintain many hours of employment, which restricted their study time).
Nursing Program Characteristics
Nursing programs seek to admit students who are the most likely to be successful in achieving program outcomes. Establishing admissions criteria that require adequate reading, writing, and math skills and success in biological and behavioral science courses is essential to admit students with the highest potential for success (Fraher et al., 2008; Jeffreys, 2004; Newton, Smith, & Moore, 2007; Seago & Spetz, 2008). Because the mission of community colleges is to provide equal access to educational programs, a selective admissions process, rather than a waiting list or lottery process, may be considered inconsistent with the mission (Seago & Spetz, 2008). A potential solution to the dilemma of program admission in the study by Seago and Spetz (2008), conducted in all community colleges in California, was to recommend that admission policies be standardized for all of the state programs, with a portion of program seating being retained to offer to students who excelled in prerequisite course work and would likely be successful in the program.
Faculty expert knowledge, effective teaching strategies, and support for students affect success. In addition to being experts in their content area and in educational strategies, faculty must also be knowledgeable about the current test plan for the NCLEX and administer well-written test items that promote clinical decision making and critical thinking. Faculty support and academic services have been found to influence student achievement and persistence in coursework (Cotten & Wilson, 2006; Jeffreys, 2004; Rugutt & Chemosit, 2009; Shelton, 2003). Faculty support is demonstrated by learning students’ names, providing a positive classroom or clinical environment, providing timely feedback on students’ performance, and directing students to learning resources. Academic services assist students in being successful by offering orientation programs, tutoring, arranging peer study groups, providing academic and financial advisement, and offering library resources (Cotten & Wilson, 2006; Jeffreys, 2004; Rugutt & Chemosit, 2009; Shelton, 2003).
Student Outcomes and Attrition
Two major student outcomes of interest to nursing programs are program completion and success on the NCLEX. Achievement on the NCLEX, particularly on the first attempt, is a quality indicator for nursing programs and is seen as evidence that students were adequately prepared by a rigorous educational program and that the graduate demonstrates knowledge required for a beginning practitioner (National Council of State Boards of Nursing, 2008).
Attrition, or withdrawal, is another possible outcome for the student but is considered to be undesirable for students, programs, and the health care industry. Students may withdraw voluntarily from their studies for personal reasons, or they may go through involuntary withdrawal due to poor academic performance if they are unable or unwilling to meet academic standards. Voluntary withdrawal from college is not always negative and may be in the best interest of students who do not have a clear goal in mind or who are overwhelmed with family or financial obligations (Jeffreys, 2004). However, in the case of involuntary withdrawal, students may experience discouragement about their inability to complete a program and feel they have wasted time and money. Students who are dismissed may experience embarrassment and lowered self-confidence (O’Donnell, 2009). The effects on the nursing program include empty program seats and a loss of tuition revenue. Fewer nurses are graduated, which affects the pool of available practitioners in the workforce.
This retrospective study of nursing student success was conducted in the PN and ADN programs of a community college setting. Comparisons were made of course completion, program completion, and NCLEX test success between the 2-year period with the intervention and the 2 years immediately preceding the intervention.
The intervention instrument was a 1-page plan that combined faculty support with use of academic resources. The intervention plan was completed by faculty to identify course objectives and requirements that were not being met; to identify instructor-recommended resources, such as tutoring, technology tools, and advising; and to require the student to write a brief action plan about changes needed in their academic work, behavior, or attendance. The plan served as documentation that the meeting between the faculty member and student had taken place and that the student understood that failure to satisfactorily meet the course requirements would result in failure of the course.
Students were placed on an academic intervention plan when their examination scores were consistently lower than the 76% passing score rate required in theory courses or when there were deficiencies in applying theory to practice in clinical settings as evidenced by poor preconference presentation, incomplete medication knowledge, or failures in written care plans or concept maps. An intervention plan for behavioral reasons was based on inadequate follow through in the provision of nursing care, incomplete documentation, failure to meet the dress code for clinical rotation, or unprofessional or unsafe behavior with patients, families, staff, or instructors. Failure to meet attendance requirements or tardiness resulted in an intervention plan for attendance.
Approval was received from the appropriate institutional review board, and permission to review the students’ records was granted from the community college. A convenience sample was accessed through electronic records of class rosters and individual student college files. Study records of 384 students included 193 practical and associate degree nursing students enrolled in the program during the years prior to the intervention and 191 practical and associate degree nursing students who were enrolled during the years with the intervention plans. Inclusion criteria required that the students were admitted in and were scheduled to complete the programs within one of the 2-year periods.
Data were accessed from student electronic records and entered into SPSS version 16.0 software by the researcher (C.J.H.). Percentages were calculated and chi-square analysis was performed to determine whether any significant differences existed between groups because the data were nominal and categorical.
Demographic characteristics of age, ethnicity, and gender for the students over the 4-year period are presented in Table 1. Students’ ages were classified as traditional if the students were younger than 25 years or nontraditional if students were 25 years or older. Few male and ethnically diverse students were enrolled during both time periods. Ninety-two percent to 95% of the students were female, and approximately 63% of the students were nontraditional.
Table 1: Demographic Characteristics of Students Enrolled (N = 384)
Nursing Student Success in Program Completion and on the NCLEX
Data were collected for student enrollment, retention, course-work failure, program completion, and success on the NCLEX (Table 2). More PN students were admitted than ADN students due to the shorter length of the PN program and additional entry points. The program completion and retention rates for the PN students were 74% during both time periods and were lower than the completion and retention rates of 86% and 88% for the ADN students. One ADN student in the period prior to the intervention and three ADN students in the intervention period began in the ADN program but completed the PN program at the recommendation of program faculty.
Table 2: Nursing Student Success in Program Completion and on the NCLEX®
Nine students (5%) withdrew voluntarily from the programs during the years prior to the intervention plans, and 16 students (8%) withdrew voluntarily during the intervention years, which represents an increase of seven additional voluntary withdrawals and was an unexpected finding. Students withdrew voluntarily for a variety of reasons during the intervention years, including geographic relocation, ineligibility to continue in the program due to court proceedings, lack of interest resulting in change of major, and overwhelming family needs, with one student providing care for her grandchildren and needing to defer her education to a later time.
Fifty-one students (26%) failed one or more nursing courses in 2005–2007 prior to the intervention, and 40 students (21%) failed nursing coursework in 2007–2009 during the intervention years. Thirty-four students (18%) were involuntarily withdrawn due to academic failure during the years prior to the intervention, compared with 23 students (12%) who were involuntarily withdrawn during the intervention years. There were 11 fewer students (6%) who were withdrawn involuntarily due to academic failure during the years with the intervention plan, which was an important finding. NCLEX success rates for the students who completed the program and were eligible to take the examinations averaged 91% for all of the groups.
Demographics and Program Completion
The difference between gender and program completion during both time periods was nonsignificant. The race variable was not calculated to determine differences in program completion due to insufficient numbers in the cells. The chi-square for age (traditional versus nontraditional students) and program completion was statistically significant in the years prior to the intervention, χ2 (1, n = 193) = 10.09, p = 0.001, indicating that traditional students were less likely to complete the program than nontraditional students. This finding for age and program completion is in contrast to the years with the intervention, which found no significant difference, and suggests that the intervention helped eliminate the difference in success between the age groups.
Intervention Plans and Student Success
One hundred eighteen intervention plans were implemented with the students during the intervention period. Twenty-two (30%) of the 74 ADN students received an intervention plan, compared with 45 (38%) of the 117 students enrolled in the PN program during the intervention years. Nineteen (86%) of the 22 ADN students with intervention plans completed a program (three completed the PN program). Twenty-seven (64%) of the 45 PN students with intervention plans completed the program (four withdrew voluntarily after receiving the plans). Sixteen ADN program completers (84%) and 26 PN program completers (96%) who took the NCLEX passed on the first attempt. This is evidence that students who were retained through the use of intervention plans were capable of program completion and NCLEX success and were not merely retained regardless of the ability to be successful.
However, there is no evidence that the minimal change in the pass rates from the years prior to the intervention compared with the intervention years was due to the effectiveness of the intervention, rather than change in the national passing average for the NCLEX.
One ADN student and five PN students who failed course-work and were involuntarily withdrawn from the program were not placed on intervention plans prior to failure for reasons unknown to the researcher. This represents a 92% compliance rate with administration of the intervention plans by nursing faculty.
Comparison of Single Versus Multiple Intervention Plans and Student Success
Thirty-three students received a single intervention plan, compared with 34 students who received more than one plan. Of the 33 students who received one plan, 25 (76%) were retained and completed the program. When multiple plans (two, three, or four) were received, only 21 (62%) of the 34 students were retained to program completion. Although students with multiple plans appeared to be less likely to complete the program than those with a single plan, this finding was not statistically significant, χ2(1, n = 67) = 0.943, p = 0.33.
Reason for Intervention Plans and Program Completion
Eighty-six (73%) of the 118 intervention plans were written for academic reasons, 10 (9%) were written for attendance reasons, 6 (5%) were written for behavioral reasons, and 16 (14%) were written for a combination of reasons. Sixty-seven percent of the students with academic intervention plans went on to program completion, and 60% of students who received a plan for attendance went on to program completion. Only 33% of the students who received an intervention plan for behavioral reasons completed the program, and 45% of those who had a combination of reasons for a plan completed the program. Although these findings suggest that students receiving an intervention plan for behavioral or a combination of reasons were less likely to complete the program than those who had received one for other reasons, the sample size was too small to achieve significance.
The primary aim of this study was to determine whether the intervention plans made a difference in the student outcomes compared with years without the intervention plans. Fewer involuntary withdrawals due to failure during the years with the intervention were noted. An unexpected finding was the increased number of PN students who voluntarily withdrew for personal reasons during the later years of the study, as all students had been on a waiting list to enter the program and had demonstrated success in prerequisite general education requirements. The voluntary withdrawals were for reasons related to family responsibilities and goal determination, which are student characteristics displayed in the conceptual model.
The second aim was to determine whether demographic characteristics were related to program completion over the two time periods. No significant difference by gender was noted, but there was a statistically significant (p < 0.001) finding that traditional students were less likely to successfully complete the program than nontraditional students during the years prior to the intervention. This is consistent with several of the studies that found nontraditional students were more likely to complete a program than traditional students (Fraher et al., 2008; Mulholland et al., 2008; Pryjmachuk et al, 2008). Traditional students improved their performance with the plans during the years with the intervention and improved their success on the outcome measures.
The third aim was to determine whether students who received a single intervention plan were more likely to be successful than those who received intervention plans for two or more courses. Students with a single plan were more likely to complete a program than those with two, three, or four plans. Three ADN students who received more than one plan were recommended to transfer to the PN program and were successful in completing the program and the NCLEX-PN, thereby avoiding the loss of time, energy, and money that would have occurred if they had failed coursework in the ADN program and were then involuntarily withdrawn.
The fourth aim was to compare the reason for the intervention, whether academic, behavioral, or attendance, and program completion. The majority of plans were for academic reasons. The students who received a plan for behavioral reasons were least likely to complete the program. McLaughlin, Moutray, and Muldoon (2008) studied personality, self-efficacy, and nursing student success and found that students were more likely to withdraw from a nursing program if they exhibited certain behaviors and personality traits such as aggression, apathy, and impulsiveness. Although the behaviors that students received plans for were not specific personality traits, student interest in or ability to comply with program requirements may have been less with these students, which affected their success.
This study was retrospective and the study records were limited to students who began and were scheduled to complete their nursing programs of study from August 2005 to July 2007 and from August 2007 to July 2009 (4 consecutive academic years) in one community college setting with limited ethnic diversity in the midwestern United States. This limits the generalizability of the findings to other nursing programs. There was only 92% faculty compliance with administration of the plan, as six students who failed coursework and experienced involuntary withdrawal were not placed on intervention plans prior to failure. Another limitation was the minimal instruction given to full-time and part-time faculty about how to administer the intervention plans, recommend resources, and assist students in developing action plans while demonstrating support for the student. This may have contributed to variance in the implementation of the intervention.
Recommendations include use and evaluation of the intervention plan in other nursing programs when a student is not meeting course objectives or requirements and is at risk for failure in coursework. Faculty should receive education about the importance of faculty support to student success and effective plan implementation, including at what point in a course to initiate a plan, learning resources to recommend, and how to assist the student to develop an action plan for improvement. Identifying resources for students who receive an intervention plan for behavioral reasons is needed if the demonstrated behavior is beyond the scope of advisement by nursing faculty.
Replicating this study in other nursing programs is recommended with data collection on the actual usage of instructor-recommended resources and student perceptions of faculty support with administration of the plan to determine whether the student perceived the interaction as punitive or helpful. Student success policies with mandatory tutoring and academic advisement sessions should be developed and researched for students who receive more than one plan.
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Demographic Characteristics of Students Enrolled (N = 384)
|Variable||Prior to Intervention (2005–2007;n= 193)||During Intervention (2007–2009;n= 191)|
| Female||184 (95)||175 (92)|
| Male||9 (5)||16 (8)|
| Caucasian||186 (96)||178 (93)|
| Hispanic||4 (2)||10 (5)|
| African American||2 (1)||2 (1)|
| Asian||1 (0.5)||1 (0.5)|
| Traditional (< 25 years)||74 (38)||71 (37)|
| Nontraditional (⩾ 25 years)||119 (62)||120 (63)|
Nursing Student Success in Program Completion and on the NCLEX®
|Category||Years Prior to the Intervention||Years with the Intervention Plan|
|Program completion||54 (1 PN)a||96||150||65 (3 PNs)a||86||151|
|Completion rate (retention rate, %)||86||74||88||74|
|Voluntary withdrawal||3||6||9 (5%)||5||11||16 (8%)|
|Students who failed nursing coursework||11||40||51 (26%)||9||31||40 (21%)|
|Involuntary withdrawal||6||28||34 (18%)||4||19||23 (12%)|
|NCLEX success (%)||87||93||91||93|
|National average (NCLEX) (%)||85||87||88||86|