Combating attrition: Why do academically competent students drop out of associate degree nursing programs
v T able of Contents Acknowledgments iv List of Tables vii List of Figures viii CHAPTER 1. INTRODUCTION 1 Introduction to the Problem 1 Background of the Study 4 Statement of the Problem 9 Purpose of the Study 10 Theoretical Framework 10 Research Questions 12 Significance of the Study 13 Definition of Terms 14 Nature of the Study 15 Approach to Inquiry 16 Assumptions and Limitations 17 Organization of the Remainder of the Study 17 CHAPTER 2. LITERATURE REVIEW 19 Overview of the Chapter 19 History of Student Attrition in ADN Programs 19 Tinto’s Longitudinal Model 22 Application of Tinto’s Longitudinal Model 32 Summary 42
CHAPTER 3. METHODOLOGY 44 Introduction 44 Hypothesis and Research Questions 44 Research Design 45 Setting of Study 49 Sampling Procedure 50 Instrumentation 52 Data Collection Procedure 55 Ethical Issues 59 Data Analysis Procedures 60 Summary 61 CHAPTER 4. DATA PRESENTATION AND ANALYSIS 64 Data Presentation 64 Data Analysis 84 Findings 90 Summary 97 CHAPTER 5. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 99 Summary 99 Conclusions 101 Practical Implications 106 Recommendations for Future Research 107 REFERENCES 109
vi i List of Tables Table 1. Preentry Characteristics of Sample (N = 10) 66 Table 2. Preentry Attributes 67 Table 3. Student-Related External Variables 69 Table 4. Institutional Variables 70 Table 5. Academic Integration 71 Table 6. Social Integration 72 Table 7. Goal/Institutional Commitment 73
vi ii List of Figures Figure 1. Demand and supply forecasts for RNs 5 Figure 2. Graduation rates for different nursing programs in California 8 Figure 3. Results for mathematics ACT scores 25 Figure 4. Results for science ACT scores 26 Figure 5. A model of contributing factors for student departure 105
1 C HAPTER 1. INTRODUCTION
Introduction to the Problem The transformation of an industrial society to a knowledge-based global economy is evidenced by the growing demand for knowledge both in technical knowhow and knowledge of attributes such as information and awareness. Globally, higher education institutions are struggling to fulfill the increasing demand for a well-trained workforce. The major challenge facing postsecondary schools everywhere is the problem of attrition or decrease in number of attending students, which has been around for the past 100 years, keeping the institutional graduating rate at the 50% mark (Tinto, 2006). In spite of increased computing power, reduced communication costs among people, and the expansion of modern educational opportunities such as online and hybrid courses, postsecondary educational institutions’ attrition rates remain high (Tinto, 2006). One of the areas seriously affected by the shortage of a trained workforce is the healthcare industry, and this sector is facing a severe shortage of nurses. Global demand for trained nurses continues to grow while projections for supply decline in many developed and developing countries (Buchan, 2003). Countries like the United States, Canada, the UK, Australia, and others have an aging nursing workforce that requires new recruits to replace outgoing ones in order to continue providing care to the increasing patient population (Buerhaus, Auerbach, & Staiger, 2000). To deal with the current nursing shortage, organizations within different countries are working on policies focusing on four main areas: improving retention,
2 br oadening the recruitment base, attracting nurses who are willing to come back into the profession, and importing nurses from other countries (Buchan, 2003). The United States has its share of the student attrition problem in higher education institutions throughout the nation, and the high attrition rate and other related educational problems have been topics of debate within college communities for quite some time (U.S. Department of Labor [USDL], 2007). In the 1970s and 1980s, the primary focus of the debate was access to higher education and corrective measures aimed at reducing the barriers to access. By the mid-1990s, the focus of discussion moved to the issues of choice, affordability, and persistence (Swail, 2004). Despite the tenfold increase in postsecondary enrollment since the mid-1990s, the nation’s institutional retention rate has remained at the 50th percentile mark, indicating that half of the students entering higher education institutions fail to graduate, and the attrition problem of higher education appears to be closely related to a problem in persistence (Swail). The United States ranks in the bottom half (16th of the 27) of countries with data on the proportion of students who have completed college certificates or degree programs and ranks behind the top five countries in the percentage of 20- to 24-year-olds with high school credentials (Gordon, 2006). Changes put in place by state legislatures to allow access to college education for underrepresented student populations have opened the doors of higher education to the diverse residents of the community and brought change in the nature of the student body and postsecondary schools’ retention rates. Research data collected from beginning postsecondary students (Swail, 2004) showed that (a) 25% of all students who entered postsecondary school for the first time switch to another institution before graduation; (b)
3 c lose to half (46%) of first-time students who left their initial postsecondary institution in the first year did not come back to postsecondary education; (c) students who did not miss school or whose attendance was continuous were much more likely to complete their degrees; (d) among the students enrolled in a 4-year college who did not delay entry into postsecondary education, 50% graduated from the first institution they entered while there was only a 27% graduation rate for students with delayed entry; and (e) 42% of students who had a 2.25 or less grade point average (GPA) in their first-year courses left school prior to graduation. Community college administrators have done their share to allow access into postsecondary education for underrepresented students by offering lower tuition and an open-access policy (Habley, 2004). Students with poor academic performance in high school, those with limited English language skills, and students with financial hardship find community colleges attractive and suitable to their needs. Besides helping students make an easier and more affordable transition to 4-year colleges, community colleges also offer special skill-training programs that prepare students with entry-level skills for the healthcare workforce. One such skill-training program offered by community colleges is the associate-degree nursing (ADN) program (California Postsecondary Education Commission [CPEC], 2003). Associate-degree nursing programs have been instrumental in preparing and supplying highly needed nurses to healthcare providers in the community. When compared to baccalaureate nursing programs, most community college nursing schools typically have more curricula offerings, better teachers, more support personnel, and
4 s horter programs than baccalaureate programs, but these favorable conditions have not helped reduce the high attrition rate in ADN programs in the past (CPEC, 2003). Every year close to 50% of the students who start nursing school programs within a community-college-based nursing program drop out of the school during the first year of schooling (CPEC, 2003). The majority of departing students withdraw from the program because they fail to meet the school requirements to continue in the program while others choose to leave the program on their own due to individual or social reasons (Habley, 2004). This mixed-methodology study has focused on dropout students from ADN programs within a community college district. Among the nine community colleges in the district, seven of them offer ADN programs, and each ADN program accepts up to 50 students each semester. According to the Legislative Analyst’s Office (LAO, 2007) report for the fiscal year 2002–2003, only 50% of the students were able to graduate from the ADN programs in 2 years’ time. This study could help gain an in-depth understanding, from the students’ point of view, of factors responsible for the attrition of academically competent students.
Background of the Study The problem of attrition is affecting all sectors of the higher education system, and this global problem is costing educational institutions and students large sums of money each year (USDL, 2007). The attrition problem affects not only the productiveness of educational institutions but also other organizations who rely on graduates of these institutions to fill their need for a trained work force.
5 T he problem of attrition, which has a direct negative effect on the supply of the trained workforce, rapidly increased the problem of the nursing shortage in the United States. As shown in Figure 1, the demand and supply data for registered nurses indicate a large gap. The nursing shortage problem reached this alarming point due to the supply of licensed nurses remaining low while the nation’s demand for newly trained registered nurses (RNs) has grown exponentially (USDL, 2007).
F igure 1. Demand and supply forecasts for RNs. From Local Solutions With National Applications to Address Health Care Industry Labor Shortages, by U.S. Department of Labor, 2007. Retrieved December 2, 2007, from http://www.doleta.gov/brg/indprof/ health.cfm
6 T he increase in demand for more nurses has been compounded by such factors as the large number of baby boomers approaching retirement age and needing increased access to healthcare services, the large number of nurses ready to retire from the work force within the coming few years, and the implementation of recent proposals by the state to reduce patient–nurse ratios (LAO, 2007). The growing nursing-shortage problem that threatens the future of the healthcare system has been a major topic of discussion for state and federal lawmakers (USDL, 2007). According to the USDL (2007), government grants totaling more than $46 million are available to be distributed across the nation to help alleviate the severe labor shortage crippling the healthcare industry. The USDL report also suggested areas that require more attention to overcome the labor shortage: (a) increasing the number of youth entering the healthcare profession; (b) looking for alternative labor pools such as immigrants, veterans, and older workers who can be recruited and trained; (c) developing alternative training strategies, such as distance learning, apprenticeship, and accelerated training; (d) working on tools and curricula for enhancing the skills of healthcare professionals that could apply nationwide; (e) increasing the capacity of educational institutions through recruitment of qualified faculty and enhanced models for clinical training; (f) working on retention strategies to encourage current healthcare workers to move into higher level positions where there is a shortage; and (g) retraining workers from declining industrial sectors to work in the healthcare industry. Examining retention rates becomes one important component in evaluating institutional effectiveness and accountability in higher education. Changes that are put in place by state and local governments to allocate funds for public institutions of higher
7 e ducation are based on the number of students enrolled and attending school (CPEC, 2003). The United States Congress by reauthorizing the Higher Education Act of 1998 allowed individual states a means of controlling public institutions of higher education utilizing a variety of measures and one such measure is retention rate (Stedman, 2002). This funding criterion prompted an increased interest in seeking student retention ideas to guide educational institutions to develop and utilize workable strategies to keep down student attrition rate. A review of relevant literature on nursing education (American College Test [ACT], 2005; Carey, 2004; Cohen & Brawer, 2003; Habley, 2004; Snyder, Tan, & Hoffman, 2004) reveals factors that contribute to the problem of attrition. However, at this time, it is not fully understood why academically competent students fail to complete the nursing programs offered by community colleges. The state of California offers postsecondary students three options to become registered nurses (RNs). The first option is to enroll in an ADN program at a community college or a 2-year private college. The second option is the baccalaureate degree in nursing program available at 4-year colleges, and the third option is the entry level master’s program offered by universities, where students who already have a baccalaureate or higher degree in a non-nursing field are accepted into the program to complete 18 months of courses to fulfill the requirements for a registered-nurse licensure exam. After obtaining their RN license, the ELM students will continue for another 18 months to obtain a master’s degree in nursing (LAO, 2007). Recent data show that, currently, the state of California has 108 public and private colleges that offer 121 prelicensure nursing programs, and three fourths of these nursing
8 pr ograms are ADN programs, offered by community colleges (LAO, 2007). Recent trends in graduation rates at California’s nursing programs, as shown in Figure 2, showed increase during the 2005–2006 school year, and close to 70% of these graduates completed their study at community-college-based ADN programs (LAO). According to the LAO (2007) report, for the fiscal year 2002–2003, out of the 6,000 students who enrolled in ADN programs, only 50% were able to graduate in 2 years’ time, one quarter (about 1,500 students) of the students needed more than 2 years to complete the program, and the remaining one fourth never graduated.
F igure 2. Graduation rates for different nursing programs in California. From Legislative Analyst’s Office, 2007. Retrieved December 2, 2007, from http://www.cinhc.org/ documents/laonursingreport.pdf
9 T he LAO for the state of California has recommended that the state should do the following: (a) develop a standardized approach for funding nursing enrollment growth and (b) assess admission policies to include merit-based criteria in conjunction with applicants’ other skills and special circumstances (LAO, 2007). The recommendation was based on the assumption that most students applying to nursing programs are returning students with skills in different areas. The majority of actions suggested in the LAO report were focused on increasing the enrollment number through providing funding for expansion. Increased enrollment could result in an increased number of graduates, but without proper retention plan in place, increased enrollment could result in higher numbers of students who are not retained. Reducing attrition rate, on the other hand, could increase the graduation rate and maximize the efficiency of the educational system (Carey, 2004). Developing an effective retention plan requires involving students in the process in order to gain a better understanding of the underlying contributing factors for the problem and ultimately to develop a workable solution. This study attempted to provide additional explanation on factors of attrition by seeking students’ input identifying the contributing factors for attrition from the students’ perspective.
Statement of the Problem A high attrition rate is a problem affecting the nation’s educational system at every level. Community-college-based ADN programs are struggling to deal with the high attrition rate that limits their ability to supply highly needed RNs to our healthcare
10 s ystem. The problem of attrition in ADN programs has not been fully understood or researched. Previous studies on the problem of attrition in nursing schools fell short of addressing the sources of the problem from the point of view of the students, either focusing largely on factors such as the overall policies of the colleges or management styles of the programs or addressing only such factors as students’ readiness and level of individual motivation. At this time, it is not fully understood why academically competent students fail to complete nursing courses offered by community-college-based ADN programs.
Purpose of the Study The purpose of this study is to understand why academically competent students fail to complete their education in community-college-based ADN programs. The study was conducted in order to develop an in-depth understanding of the contributing factors responsible for the attrition from a student’s point of view. The study focuses on identifying the underlying sources of attrition through the examination of demographic-, institutional-, and student-related variables so that the gathered information could lead to a better understanding of the contributing factors for the problem. The study findings could contribute towards developing better, more effective interventions.
Theoretical Framework The theoretical base for the study is Tinto’s (2006) longitudinal process theory that suggests that dropping out of a school program is a longitudinal process that begins
11 l ong before the act of leaving takes place. Explaining sources of attrition, Tinto wrote that multiple interactions that take place between the individual, social, and academic systems shape the student’s perception. The individual’s approach and perception of these interactions could either inhibit or enhance his or her integration within the educational community. Tinto’s model suggested that individual characteristics and the ability to integrate into a new environment together determine the degree to which students are committed to their goals and educations. Studies have indicated that different problematic factors prevent students from completing ADN programs (Habley, 2004). However, the attrition problems of community-college-based nursing programs have not been fully researched or understood. In the past, different ideas were suggested to combat attrition but most of the suggestions focused largely on 4-year baccalaureate degree programs. This study used Tinto’s longitudinal model of postsecondary student attrition as a conceptual framework to gain an in-depth understanding of the contributing factors for the attrition problem in community-college-based nursing programs from students’ point of view. Tinto’s (2006) model provides a conceptual framework because it does not limit the reasons for students’ attrition to one factor alone. Instead, the model identifies many factors that contribute to the problem, focusing on what happened to the student before and after entering the particular educational system or program. Tinto’s model was broad enough to allow the categorization of institutional and personal factors as contributing factors for attrition. Tinto (2006) suggested that dropping out of a school program is a longitudinal process that begins long before the act of leaving takes place. What separates Tinto’s
12 m odel from others is that his model focuses on circumstances of the educational institution and particular attributes and institutional experience of the student following entry into the college program. Other models seek to find weak links in the individual’s personality and background characteristics. This study’s framework was based on student-related factors suggested by Tinto (2005): preentry attributes, academic and/or institutional commitment, and the ability to integrate into the academic and social systems of the college. The study also addresses other significant conditions or factors affecting students’ persistence. Other major themes included in the theoretical framework of this research literature are studies supporting Tinto’s model focusing on Tinto’s suggestions of incorporating longitudinal follow-up data and studies using survey methods to study one college’s attrition rate by incorporating the use of path analysis. There are also several research studies not fully in support of Tinto’s model, questioning the suggestions on influence of preenrollment characteristics and individual commitments in determining students’ decisions to remain in school or leave.
Research Questions The hypothesis for the study was that institutional- and student-related factors determine the likelihood of students’ departure from associated degree nursing programs. The specific research questions for this mixed methodology study were the following: 1. To what extent do preentry attributes affect a student’s decision to persist in an ADN program?
13 2. To what extent does a student’s level of commitment to the institution affect his or her decision to persist in an ADN program?
3. To what extent does a student’s commitment to an academic goal affect his or her decision to persist in an ADN program?
4. To what extent do student-related external variables affect a student’s decision to persist in an ADN program?
5. To what extent do institutional variables affect a student’s decision to persist in an ADN program?
Significance of the Study This study is considered to be significant for the following reasons: First, there are only very limited studies of attrition on 2-year nursing school dropouts. Most of the previous studies on the subject of nursing-school attrition were focused largely on 4-year baccalaureate degree programs, where there is a much different student demographic when compared to the student population in community colleges. This study focused on students who attended 2-year ADN programs, which produce close to 70% of all RNs, and on issues that affect their persistence. Second, this study focused on the problem of attrition at ADN programs concentrating mainly on students’ point of views. Previous studies on nursing school attrition were usually concerned with finding answers to what is wrong with an institution or what is wrong with the student, leaving out other factors that also could have a serious effect on students’ persistence. Third, this longitudinal study assessed different factors that contribute to student attrition, such as preentry attributes to find out students’ level of readiness prior to starting the nursing program, institutional factors to assess students’ ability to integrate
14 i nto the academic and social system of the college, student-related external variables to find out the extent and effect of external obligations on the student’s performance, and students’ commitments to institutional and academic goals. Finally, by providing better understanding of the reasons for students’ departures from ADN programs, this study could contribute to the effort of finding a solution to the attrition problem and help alleviate the current severe nursing shortage that poses a great threat to the healthcare system.
Definition of Terms Academically competent. Refers to students who completed the nursing prerequisite courses with a GPA of 2.0 or above, as the college district requires. Associate-degree nursing (ADN) program. Refers to 2-year college programs designed to prepare entry-level RNs. The majority of ADN programs are offered by community colleges. Attributes. A variety of characteristics—including gender, race, and ability—and precollege experience, such as GPA, social and academic achievements, or social skills, are considered attributes. Commitment. Refers to the student’s agreement to working at will towards the attainment of a predetermined goal. Dropout. Refers to a student who leaves the ADN program prematurely due to academic, social, or personal reasons. The word dropout does not refer to students who “stop out” for a period of time before returning to the program, those transferred to
15 a nother nursing program that is equivalent or at a higher academic level than the original, or those who died. Integration. Refers to the state of being bonded to the college culture or academic system of the institute in one or more ways. Such bonding could be social, academic, or both. Preentry attributes. Refers to student-related factors that each student brings to the nursing program, specifically, prior skills and abilities, family backgrounds, and prior academic grades. These prior attributes may directly or indirectly affect the student’s commitments and intentions towards future educational activities.
Nature of the Study The chosen method to address the problem identified in this study was a mixed methodology. The selected method could be useful in addressing research questions about outcomes resulting from a combination of circumstances or events, where a variety of factors have combined in different and sometimes conflicting ways to result in similar outcomes (Creswell, 2003; Ragin, 2006). This design was chosen for four main reasons. First, this approach allows the researcher to preserve the rich, descriptive values necessary to obtain a variety of experiences in each individual setting (Smithson & Verkuilen, 2006). Second, the method enables the researcher to choose pertinent, theoretically substantiated contributing factors to be included in the study analysis. Particularly, those variables identified by Tinto’s model, as being the most cited in the literature on nursing school dropouts (Tinto, 2006), could be used in the analysis. Third, the chosen mixed methodology is flexible enough to
16 i dentify multiple factors and sources of complexity, a tenet of Tinto’s model (Tinto). Fourth, the approach uses qualitative and quantitative data in a synthetic form, creating a more complete description of the attrition phenomenon much better than a single research method could (Ragin, 2006; Yin, 2003).
Approach to Inquiry Mixed methodology (Creswell, 2003) was the research approach used in this study. This study adapted Tinto’s (2005, 2006) model of student attrition and the studies cited in the literature review that identified the most commonly used predictors of attrition in ADN programs. To obtain the qualitative data, the study incorporated a system for an in-depth telephone interview. The interview process provided a major source of qualitative data for the study, bringing in students’ perspectives on the schooling process and their experience throughout their involvement in the nursing program. Quantitative data for the study were obtained from two sources: data that were collected during the interview and students’ school records. For example, factors like academic grade point below the passing mark of C or 75%, unsatisfactory hands-on skill or effort, and records of absenteeism will be obtained from students’ files. The collected data were coded 1 to indicate presence or 0 to indicate absence (1 = presence; 0 = absence). This method of assigning value could also be used to code participants’ responses to interview questions used as quantitative data (Ragin, 2006; Smithson & Verkuilen, 2006). For example, students may report little or no participation in
17 e xtracurricular activities, which was coded 0 for absence, or experience of positive interactions with faculty and staff, which was coded 1 to indicate presence.
Assumptions and Limitations Assumptions of the Study The following assumptions underlie this study: 1. All community-college-based nursing programs in the community college district follow the district’s guideline to admit nursing students into their programs.
2. Prerequisite courses offered by community colleges within the community college district are equivalent in determining the competence of the students who completed these prerequisite courses and passed.
3. Students who dropped out of the participating nursing program would be willing to participate in the study.
4. Tinto’s model would provide an appropriate theoretical framework.
Limitations of the Study This study has the following identified limitations: 1. The number of participants used in the study result in a limitation on the generalizability of the study.
2. As time goes by, students’ perceptions of their nursing school experiences might also fade or alter in some way. Asking dropouts to recall events 2 or 3 years after the fact might not produce responses as accurate as would an exit interview at the time of dropping out.
Organization of the Remainder of the Study Chapter 2 presents a review of current and relevant literature on the study topic, focusing largely on studies that used Tinto’s longitudinal model to explain the academic
18 a nd social factors associated with student attrition. In chapter 3, the research methodology is discussed, along with a description of the mixed methodology used for the study. The study findings are presented in chapter 4, along with a summary of the study, and chapter 5 presents the summary, conclusions, and recommendations on the study topic.
19 C HAPTER 2. LITERATURE REVIEW
Overview of the Chapter Answering the research questions for this study on student attrition will require the ability to document how particular items of information are likely to be causally linked to students’ educational achievement and retention (Braxton, Hirschy, & McClendon, 2004). Studies that are relevant to the topic of this study in explaining the academic and social factors associated with student attrition (Braxton, 2000; Braxton et al.; Grubb, 2006; Seidman, 2005; Tierney, 2000; Tinto, 2005, 2006; Ziskn, Gross, & Hossler, 2006) are reviewed in this chapter, along with a brief history of the phenomenon of attrition at community colleges. First, a history of attrition is explored. Second, Tinto’s longitudinal model of postsecondary student attrition is presented as the main conceptual framework for the study. Third, other related studies on the issues of attrition at community college-based nursing programs are presented. Fourth, studies relating to characteristics of ADN program dropouts are compared to the longitudinal model concepts.