Every fall, nursing majors enter colleges and universities as highly motivated and academically qualified students who should be confident and prepared for higher education. However, nearly one third of these students will drop out of nursing programs, an alarming statistic for educators, administrators, and employers (Walker, 2016, p. 450). Aside from lost tuition revenue and derailed academic pursuits, the current and growing shortage of nurses is a global problem, with every nursing student needed for future professional practice. A logical first step to mitigate attrition through effective interventions is to identify barriers to progression and factors that compel students to persist. However, scant information exists in the literature on persistence from the students' perspectives. The nursing faculty at a small public university in New England face high rates of student attrition among their academically qualified students, and anecdotal evidence implies gaps in students' self-efficacy, rather than their cognitive ability, to overcome retention challenges. Therefore, the nursing faculty conducted an extensive review of current literature and historical sources, developed a pilot bridge course for incoming freshmen, and began a prospective study to elicit student insight.
This article focuses on the pilot bridge course for first-year nursing students. The nursing program is new and is graduating its sixth class at the time of the pilot. The population of the college, at just over 4,000 undergraduates, includes 43% first-generation students, 36% low-income students, and approximately 150 students who self-identified as homeless. In addition to the academic rigor of the nursing curriculum, social and financial challenges may affect the completion rate for the program, which strives to meet the benchmark set by the Commission on Collegiate Nursing Education (2018) of 70% reaching graduation in 5 years or less. Despite the statistics, some students with significant challenges do persist and become licensed RNs, and their success compels the faculty to seek student insight on effective ways to support persistence, including feedback on the pilot bridge course described here.
At the outset of the bridge course development, several questions guided the literature review on nursing student attrition and framed the course curriculum:
- What internal and external factors are perceived as challenges by nursing students?
- What internal and external factors enable nursing students to overcome perceived challenges?
- What faculty behaviors and curriculum factors support nursing student persistence?
Older literature sources expand scant available information and provide a historical perspective that illuminates the current and long-standing challenges of persistence and the need for further insight.
The global attrition rate of 30% for nursing students is a serious problem (Bakker et al., 2018; Fontaine, 2014; Mooring, 2016; Walker, 2016). The associated factors include time management, academic rigor, adjusting to college life, and stress from clinical situations (Glossop, 2002; Watson, Monson, & Marshall, 2019). Nursing students underestimate the required depth of knowledge and responsibility for practice and drop out when they feel daunted (Kukkonen, Suhonen, & Salminen, 2016). Studies yield few solutions, and little gain has been made in the past 40 years (Tinto, 2006). Nursing students may lack adequate skills to cope and persist when their expectations do not match the demands of academic and clinical learning.
Student academic performance decreases with stress, and support from staff, faculty, peers, and nurses fosters self-efficacy and persistence (Hartley, 2011). Self-efficacy is linked with effort, tenacity, perseverance, and resiliency in the face of failures and setbacks, which are qualities for persistence in a rigorous program such as nursing (Walker, 2016; Watson et al., 2019). Other factors that sustain self-efficacy include socialization and belonging, and transitions during the first year of college remain especially critical (Bandura, 1997; Mooring, 2016). Attrition for freshman nursing students may be linked to isolation (Pardue & Morgan, 2008; Pritchard et al., 2016). A study of nursing students in four universities found that socialization with peers, faculty, and nurses boosts student resiliency and persistence (Ten Hoeve, Castelein, Jansen, & Roodbol, 2017). Tinto's work on student retention and transition to college indicated the need for social support (1990, 1998), and early faculty mentoring may decrease students' sense of isolation and incompetence when the curriculum is academically and emotionally rigorous.
Reducing the attrition from nursing schools is a crucial goal for students, academic institutions, and the health care industry, and strategies must address the complex reasons why qualified and motivated students do not persist. Mentor support enables students to connect their cognitive learning, self-perception, and personal experience in ways that bolster persistence when challenges arise, promoting resiliency and self-confidence (Stolz, 2015; Williams, 2010). First-semester nursing students often underestimate the academic rigor. When the heavy workload leads toward burnout, a focus on personal resilience, belonging, and problem-solving skills emphasizes students' ability to overcome these difficulties and persist (Deary, Watson, & Hogston, 2003; Glogowska, Young, & Lockyer, 2007). Inherent in their obligation to ensure that nursing students are proficient and safe to practice, faculty should consider social and emotional preparation, as well as knowledge and skills (Jeffreys, 2007). Helping students to identify how they learn, what challenges them, and how to apply their unique coping strengths may nurture their internal motivation to succeed (Maiese, 2017; Stolz, 2015). Students who feel validated by nurse support are more likely to persist and become nurses (Adamski, Parsons, & Hooper, 2009).
Several studies examine the positive influence of orientation workshops on nursing student persistence (Fontaine, 2014; Jacobs, 2016; Pritchard et al., 2016; Tinto, 1990; Walker, 2016). Activities include reflective thinking to enable students to integrate new knowledge with existing ideas (Dearnley & Matthew, 2007), identifying habits for effective study skills (Sayles & Shelton, 2005), and collaborative projects to build relationships with faculty and peers because students who feel connected are more likely to cope and persist (Talbert, 2012; Walker, 2016). Group activities also foster student appreciation for collaborative learning, and Adamski et al. (2009) suggested using storytelling as collective meanings of caring and coping to enhance a sense of connection within the group. Winter, Hungerford, and Paget (2004) described storytelling as an imagination-based reflection exercise, which is relative to the long history of using stories in nursing education. Chan (2013) asserted that innovative activities such as storytelling increase students' abilities to think critically and recognize connections among related concepts.
Early creation of a cohort through orientations and bridge courses may exert a lasting influence for students who face the rigors and demands of a curriculum they are not adequately prepared to manage (Valencia-Go, 2005), and early identification with the nursing role may support persistence. Glogowska et al. (2007) found that the most common reason for student persistence is their desire to practice nursing, a focus that can keep challenges in proportion. Positive peer and faculty support helps students to internalize their career desires and navigate their transformation from eager freshmen to graduate nurses (Maiese, 2017). Along with strategies for studying and social participation, encouraging students to create a career vision of becoming a nurse may promote their ability to persist toward that goal (Williams, 2010).
Method: Pilot Bridge Course
The faculty at a small public university in New England support the nursing students through academic and personal advising, faculty and peer mentoring, tutoring, and social activities. Recognizing that, despite these efforts, the retention rates are no better than the global average, faculty created a voluntary bridge program for incoming freshmen titled Habits of Successful Nursing Students, mirroring the Covey (1989) title for effective people. The 1-credit free pilot program course was delivered over 2 days to dovetail with freshman orientation. Student participants moved into their dorms on Wednesday morning, had lunch with bridge course faculty and students, and engaged in course activities throughout a group dinner that evening. The students reconvened Thursday morning and completed course activities by 2:00 p.m., at which point they were encouraged to participate in university-wide freshman orientation events. This structure was intended to create a cohort model while exploring personal and collective internal and external challenges and resources for success. Details on course activities are further described in Table 1.
Five Habits of Successful Nursing Students
The curriculum for the course is derived from the literature review and discussions with upperclassmen that suggested a need for developing an internal compass for success and skills for resilience. Objectives are framed by five habits of successful nursing students: staying inspired, staying smart (How do I learn?), managing time, asking for help, and belonging to a cohort. These habits were created by the faculty based on Covey's (1989) habits of effective people. Each habit includes objectives and learning activities to amplify the topic and provide the student with self- and group-learning strengths. Students complete learning style inventories, engage in group problem solving activities, and share their personal reasons for choosing a nursing career. The highly interactive model of the course promotes self-reflection, identification with other cohort members, and a vision of success as an intentional and reachable goal. One group exercise involves storytelling through writing a collaborative fictional narrative about a student who perseveres to overcome challenges and succeed in his goal of becoming a nurse, allowing students to identify their own strengths, challenges, and strategies for success through a nonthreatening process. Overall, course activities provide a mix of cognitive, creative, reflective, and kinesthetic learning, and group meals with faculty and students promote the early development of peer and mentor relationships within a cohort model.
Results: Initial Evaluation
Evaluation of the program through multiple modes and time frames includes anonymous feedback elicited concurrently and prospectively during the students' time in the nursing program. Initial course evaluation results, using a Qualtrics® standard end-of-course survey with two additional open-ended questions, provided immediate feedback on logistics including course timing and classroom space. Qualitative inquiry, in the form of open-ended questions both in person during a midsemester forum and electronically via an institutional review board-approved Qualtrics survey, was completed at the end of the first semester. This data collection will be repeated every semester until the cohort graduates. Statistics on attrition from the program will also be collected, including reasons for leaving and any student attempts to obtain help. In addition to quantitative data, qualitative comments in the surveys each semester will be analyzed using a hermeneutic phenomenological approach. Transcripts will be reviewed to identify significant statements and formulate themes from the student narrative. The themes will be used to inform future bridge course curriculum, as well as to create a foundation of student insight into persistence.
Of the 51 freshman nursing majors, 27 voluntarily completed the pilot bridge course. Course feedback from 23 students via the Qualtrics evaluation showed 12 were extremely satisfied, nine were moderately satisfied, and no students reported dissatisfaction. Themes from responses on what students liked most about the course include Meeting Peers and Making Friends (17), Meeting Faculty (4), and Gaining Insight on the Nursing Program Expectations (5). Narrative comments highlighted working with peers to form friendships and solve problems, meeting other nursing students, and identifying tools for success. Respondent suggestions for continuous program improvement include additional small-group activities, meeting upperclassmen nursing majors, and scheduling an ongoing class for continued peer support.
At the conclusion of the first semester, 85% of the freshman class progressed to the spring semester, and 23 of the 38 students who progressed had taken the bridge course. Although the full effect of the program will not be known until the cohort graduates in 2022, faculty who taught the bridge course observed enthusiastic participation, a high level of peer engagement among students who had not known each other previously, and a palpable sense of cohesive belonging. By late afternoon of the first day, students were exchanging personal information, and they arrived the next morning in talkative groups rather than as singular students. One student shared, “I went in very nervous and I already have new friendships and I have people to ask for help.” The collaborative narrative is one example of how group activities fostered solidarity. As students participated in expressing details and alterations to the plot, their engagement was positive and humorous and included personal situations as insight into how the fictional story should unfold. Through this creative exercise that related to their own lived experiences, students identified complex challenges and support strategies for their own nursing education. Along with identified skills for success from specific activities, participants left the bridge course articulating peer and faculty connections and a strong sense of belonging to their cohort.
Persistence in schools of nursing is a local and global problem. Although faculty carry responsibility for preparing nursing students to become safe, competent, and confident graduates whose practice will help alleviate the nursing shortage, they also nurture persistence through mentoring and socialization into the profession. Amidst complex challenges and minimal documented successful persistence strategies, one logical starting point is to offer an early welcome and introduction to nursing students to address their need for learning, intrinsic motivation, confidence, and connection with peers and faculty. By incorporating cognitive, behavioral, and affective factors, the bridge course is designed to prepare students for the academic and emotional rigors of nursing education and may foster the resilience and use of external support students need to persist toward graduation and professional practice. Because longitudinal data on nursing student persistence is especially scant, faculty plan ongoing communication with this cohort to elicit impacts of the bridge course and unfolding needs for support as these students progress in their education. The faculty plan to make revisions to the course based on student feedback and offer it again to the incoming 2019 freshman cohort.
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Five Habits of Successful Nursing Students
|Habit||Objective||Content and Strategies|
|1: Stay inspired||Relate the critical components necessary to persist in the nursing program.||Topic: Visualizing oneself as a nurse
Why I want to be a nurse essay
Share aloud with group
|2: Study smart||Identify personal learning styles through use of the learning style inventory.||Topic: Overview of learning styles
The learning style inventory
Complete a success plan
Review in class
|3: Manage your time||Describe the abilities and behaviors of effective time management.||Topic: Overview of the day in the life of a student
Complete the time management pie chart
Discuss your approach to time management
|4: Ask for help||Examine personal stress indicators and create a plan for managing stress during school.||Topic: Overview of stress
Strategies to manage daily stress
Perceived stress scale
Identify campus and personal resources
|5: Belonging||Explore ways to connect to nursing students and the nursing department.||Topic: It takes a village to raise a nursing student
Boat activity (kinesthetic group problem solving)
Storytelling: collective narrative
Sharing university social resources