The problem of nursing student attrition is a global concern (Merkley, 2016). As many as 50% of nursing students leave programs in the United States without graduating (Harris, Rosenberg, & O'Rourke, 2014). According to the Health Resources and Services Administration (HRSA), more than one million RNs are expected to retire in the next 10 to 15 years, leaving a deficit in the required nursing workforce (HRSA, 2013). The increased demand for nurses, coupled with the declining numbers of RNs in the workforce, mandates more nursing students graduate from accredited schools of nursing (Mooring, 2016; Urwin et al., 2010).
Although a certain degree of attrition is not preventable, interventions aimed at assisting nursing students to develop effective learning skills and habits are imperative to ensure academic success and to meet growing health care demands (Colleges of Nursing, 2019; Institute of Medicine, 2010; Wernersbach, Crowley, Bates, & Rosenthal, 2014). Nursing faculty members are particularly concerned with ensuring the academic success of students entering the professional component of nursing school. Students who report academic success in the prerequisite courses with minimal effort often find themselves struggling with the study skills and critical thinking necessary for nursing school (Felicilda-Reynaldo, Cruz, Bigley, & Adams, 2017).
The literature abounds with studies examining nursing student behaviors impacting success and actions placing students at risk. Characteristics of successful nursing students include involvement with nursing instructors and the utilization of academic resources (Guy, Byrne, & Dobos, 2018; Tharani, Hussain, & Warwick, 2017). Attitudes and actions associated with self-efficacy, ability to manage multiple roles and obligations, and stress management are also important to success (Cox-Davenport, 2017; Walker, 2016). The inability to manage stress may lead to denial and subsequent procrastination or unrealistic goal setting, resulting in attitudes of defeat (Altiok, & Üstün, 2013; Cox-Davenport, 2017; Galbraith, Brown, & Clifton, 2014). Success in nursing school requires good study strategies and distraction reduction. Study strategies include management of time, effective utilization of required textbooks, note taking, locating and utilizing available resources, and effective test taking strategies. Students who are unable to adequately develop the necessary tools for success are more likely to leave the program (Dwarika-Bhagat, Sa, & Majumder, 2017; Felicilda-Reynaldo et al., 2017; Wernersbach et al., 2014).
Nurse educators seek to understand factors influencing nursing student success. Assessment tools completed by students to identify barriers to academic success are beginning to appear in the literature. Ferrell, DeCrane, Edwards, Foli, and Tennant (2016) and McLain et al. (2017) introduced assessment forms consisting of closed-ended Likert-style questions. However, closed-ended questions may not offer students the unique opportunity to explore how personal choices and behaviors contribute to academic success.
The GROWTH (Growth, Readiness, Opportunity, Work, Time management, and Habits) form was developed to promote student retention and academic success. The form includes 18 open-ended questions aimed at identifying affective, psychosocial, and environmental variables commonly known to impede nursing students' success (Table 1). The tool is intended to be completed by nursing students prior to meeting with a faculty member. The open-ended design differs from the limited answer assessments developed by Ferrell et al. (2016) and McLain et al. (2017), allowing for more in-depth contemplation by the student of their academic issues. The GROWTH form was developed by faculty concerned for students' success in the nursing component. The form was founded on a literature review that identified common reasons students experience difficulties in nursing school. Several faculty began using the tool on first-year professional component nursing students who required academic counseling, after which students were asked to give feedback on the form. Since its inception, several iterations of the tool have occurred based on faculty and student feedback. The GROWTH form was developed to offer a consistent approach to academic counseling. Undergraduate nursing faculty at two public universities in the United States from two different states reviewed the GROWTH form for content validity. Question refinement occurred based on faculty feedback, with additional revisions occurring after pilot use and student feedback. To date, faculty have utilized the GROWTH form in academic counseling sessions with more than 300 undergraduate nursing students, in both traditional and accelerated programs of study, at three different public universities.
Affective questions on the GROWTH form seek to identify and clarify student attitudes, goals, and motivations for learning and success. The student is asked to identify sources of difficulties, to reflect on potential influencers of success, and about preparation for class and examinations. Discovering whether the student prepares for class provides the faculty member with valuable insight into student motivation and determines whether the student is exposed to the course material for the first time in class or if class discussions build on the student's class preparation. Students are asked to report when they begin to study for an examination in the course. The timing of when the student starts studying for the examination affects the retention of the material. Knowing whether the student started studying a night or two before the examination versus studying more than a week before the examination will help tailor the corrective strategy.
The GROWTH form contains questions exploring psychosocial influencers occurring in the life of the student prior or during the examination. Reflecting upon life events occurring before an examination guides the faculty member to discern whether performance on the examination was attributed to a single incident such as a family emergency or a major traffic delay, or whether the student is facing ongoing issues that may continue to impact examination performances. Information relating to testing anxiety and strategy are garnered with questions specifically directed toward the examination time.
Students also answer questions about outside school-related commitments such as the marching band, a school athletic team, or participation in student organizations. Additionally, the student is asked about their living arrangements and whether other outside responsibilities, such as the care of young children or elderly parents, compete for the student's time. Assessing the living situation assists in the discovery of unavoidable domestic obligations. Determining the student's commitments provides the student and faculty member necessary information for developing a realistic time management plan.
Environmental questions examine the student's work, home, and financial situations. The student is asked questions about employment, such as “Are you working? How many hours? Where? Doing what?” Determining what the student's work entails assists the faculty member to identify whether the student has opportunity to study at work. If the student does study at work, the GROWTH form illuminates whether the student studies routinely at work and helps to determine the frequency of interruptions experienced by the student. Although studying where frequent interruptions may occur is not desirable, some students who need to work may not have a choice. After the student and faculty member review study habits in the workplace, the faculty member then guides the student in more effective strategies and helps the student to set realistic expectations of work and nursing school. For example, in a busy work environment, the faculty member may recommend using study time to complete homework or to create a concept map, rather than activities requiring serious concentration.
Additional questions regarding studying include asking the student specifics about his or her study environment. Knowledge of the study location assists the faculty member and student to identify whether the environment is conducive to studying. The question regarding study location requires details. For instance, the response “at home” is not specific enough to assess the study environment. A response such as “on my couch with the TV on” provides key information that may have impact on the quality of the studying. If the student discloses a less than ideal study location, a change in venue may easily remedy the problem. Important information is gleaned from learning when or at what time the student is studying. If the student reports studying at times when he or she is tired and less focused, benefits of the study session may be lost. For example, if a student reports studying until late at night but claims to be a morning person, study time will need to be altered.
Implementation of the GROWTH Strategy GROWTH Form
Initiation of the GROWTH form occurs at the point of student–faculty contact regarding risks associated with course academic success. Students submit the completed GROWTH form prior to the scheduled appointment. In the event the student does not complete the GROWTH form prior to the meeting, the faculty uses questions from the tool to structure the student–faculty discussion. Faculty willingness to meet with students communicates concern and caring and fosters human connectedness—necessary for a trusting relationship between student and faculty member. The GROWTH form serves as a framework to guide faculty and student to discover factors hindering success in the course. After the factors are identified, the course faculty and student work together to develop a plan for academic achievement.
Documentation and Follow Up
Documentation of meetings include the meeting date, discussion summary, and the negotiated action plan. Faculty e-mail the student a few days after the initial meeting to promote student accountability and facilitate caring student–faculty relationships. Should the student request additional meetings, the course faculty accesses the original GROWTH form and action plan and explores whether the student implemented recommended modifications to study habits. Currently, completed GROWTH forms are kept by individual course faculty for varying lengths of time. Faculty update the GROWTH form as student circumstances change or request the student to complete a new form in subsequent semesters.
To assess the perceived value of the GROWTH form, faculty members teaching at the university were informally interviewed following implementation. Faculty perceptions of the form were positive. The GROWTH form utilization was predominantly by faculty teaching in the first-level courses of the professional component. Faculty using the GROWTH form as a framework for guiding meetings with at risk students reported satisfaction with the tool. Faculty described the intentional exploration of variables potentially hindering student academic success helpful to working with the student to develop an individualized study plan.
Faculty members observed that the 30-minute meeting time was optimized fully when the student completed and sent the GROWTH form prior to the meeting. As such, the meeting time was primarily used for developing a customized plan of action, planning for referrals, and coordinating ancillary university services rather than completing the form. Faculty discovered that students failing to complete the GROWTH tool prior to the meeting were less likely to attend subsequent meetings or adhere to the negotiated plan of study. Faculty enlightenment occurred frequently with unexpected responses on the GROWTH, which ranged from not wanting to disclose a known learning disability to food insecurity to single motherhood to domestic violence and even student homelessness. When these issues were discussed, appropriate community resource referrals were provided to the student including, but not limited to, the office of disability services, student counseling services, domestic violence shelters, food pantry information, or United Way resources.
Faculty members reported increased awareness, caring, and concern for the complexities of the students' school–work–life balance after using the GROWTH form. and follow up with students after the initial meeting. Furthermore, faculty reported use of the GROWTH form to develop an individualized plan of study helped create a more meaningful student–faculty relationship. Student–faculty relationships were viewed as partnerships, where contributions were encouraged and valued. Students frequently contacted course faculty to share positive outcomes from other classes, attributing a portion of success to the self-reflection encouraged by use of the GROWTH form. Students who have immature study habits have the benefit of engaging with a faculty member who displays care for the student, yet holds the student accountable for personal successes and growth.
Students' perceptions of the GROWTH form were informally assessed after the academic counseling session. Students indicated the GROWTH form provided insight to study habits and barriers to effective learning. Students expressed that the GROWTH form encouraged a self-assessment of their study habits and academic efforts and prepared them for a productive meeting with course faculty. Students also stated that leaving the meeting with an individualized plan of action provided hope. Finally, students reported a feeling of having “closer” relationships with faculty. Students who did not complete the GROWTH form prior to the meeting reported similar feelings. Commonly cited reasons for not completing the form prior to counseling included lack of time, belief the form was optional or for internal self-reflection only, and belief the form would be completed during the counseling session.
Challenges and Opportunities
Use of the GROWTH form was perceived positively by faculty and students in our institution. However, whether use of the form in the professional component of a nursing program has an impact on retention rates has yet to be determined. Formal testing of the form as an academic counseling tool for reducing attrition would provide evidence needed to support form use. Research is also needed to determine whether the form includes the appropriate questions, course success rates improve, student attrition rates decrease, and even whether the process used to implement use of the form has an effect.
The need for strategic implementation of the tool is as important as use of the tool for structuring academic counseling. In our institution, the lack of a central repository for archiving completed GROWTH forms and student–faculty meeting notes prevents the seamless flow of information needed for academic counseling. If strategically developed, a central repository would not only provide faculty access to pertinent academic counseling information, but could proactively identify behaviors placing the student at risk for success. Use of the university's learning management system has been suggested as a solution to these issues.
Implementation of the GROWTH form in time-constricted environments, such as part of term or accelerated courses, has been a challenge. Studies are needed to examine the length of time students need to implement study recommendations to achieve optimal academic outcomes. Furthermore, students frequently need multiple follow-up sessions to master school–life balance and implement study habits resulting in consistent academic success. Students may perceive a lack of faculty interest and concern if consistent follow-up is not maintained. Ideally, these students would be referred to a single person for academic counseling, such as a retention coordinator. The large class sizes, coupled with the amount of time necessary to work with students, makes the case for a retention coordinator. This position is under consideration at our university.
Student retention is a concern of nurse educators. The use of an open-ended question assessment tool may lead to identifying study habits and other factors that may negate student success in poor-performing students. The GROWTH form is suggested as an open-ended tool that can guide the development of a customized study plan. Completion of an open-ended question assessment tool is recommended prior to the initial faculty–student meeting to assess factors potentially contributing to student's poor performance and consider resources for success.
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What are you having trouble with in your course(s)?
If you were referred for failing an examination, what was going on in your life before this examination?
Are you working? How many hours? Where? Doing what?
Do you live with anyone?
Do you have any outside responsibilities? (i.e., young children, take care of elderly parents)
Do you have any other outside commitments? (e.g., on the soccer team)
Tell me about your study habits.
Do you do anything/prepare before class starts?
When do you start studying for an examination?
Where do you study?
What times are you studying?
How often in one week do you study for the course you were referred for?
What kind of learner are you?
How much sleep do you usually get?
What do you do the day of an examination?
When you receive your examination, do you look at the questions and then the answers or vice versa?
Do you cover your answer choices and think about what the answer should be?
Do you skip questions you don't know?
Do you change your answers?