A Qualitative Study of Nursing Student and Faculty Perceptions of Attrition

Institutions of higher learning struggle to supply enough Registered Nursing Professionals to meet demands in today’s healthcare environment. Hundreds of thousands of students are accepted into nursing programs each year, though many fall short of program completion. High attrition and low retention in registered nursing programs is a problem. The purpose of this qualitative study was to evaluate attrition and retention of registered nursing students over a four-year period at a Technical College in Georgia to determine factors impacting successful completion of the Associate of Science in Nursing Program (ASN). It further proposed to identify possible solutions to reduce attrition among nursing students. This study analyzed nursing student and nursing faculty perceptions on the causes of high attrition and low retention and perceived solutions to attrition rates. This study provides insight in the development of steps to decrease attrition in registered nursing programs, and other higher education programs of study.


Introduction
Nursing has been in a continual battle to remain a respected profession due to the challenge of acquiring and retaining highly qualified nursing professionals (DeLack et al., 2015). To meet this challenge institutions of higher learning are tasked with retaining nursing students to program completion and subsequent passing of the National Council Licensure Examination for Registered Nurses (NCLEX-RN). High attrition and low retention in nursing programs has remained problematic which affects completion rates and ultimately the supply of nursing professionals in the workforce (Peruski, 2019).
The problem addressed by this study was high attrition in undergraduate registered nursing programs. Multiple issues have been identified that increase attrition and lower retention in health education programs of study, namely nursing. Among some of the reported causes are stress and anxiety and often the learner's inability to remain motivated (Senturk & Dogan, 2018).
Nursing programs have lost students as a result of a variety of stressors in academic, social, and/or external environments. It has also been concluded that stress, coping, anxiety, and lack of coping skills affect students' ability to learn and thus contributed to attrition (Labrague et al., 2017;Turner & McCarthy, 2017). The anxiety that looms while learners are in nursing programs can intensify as they progress to the end of the required coursework (Li et al., 2015).
Despite admission criteria that should ensure success of the student, nursing programs have continued to lose students at alarming rates. Retention and attrition in higher health education remains a focus as it has a direct effect on student, institutional, and societal success (Northall et al., 2016).
The purpose of this study was to evaluate attrition and retention of registered nursing students between 2015 and 2018 at a Technical College in Georgia to find what factors impact successful completion of the Associate of Science in Nursing Program (ASN). The study has utilized semi-structured interviews as a means to recognize how students and faculty interpreted and found meaning in their own unique life experiences and feelings in regard to attrition (Jacobsen, 2017). High attrition and low retention in community and Technical College nursing programs play an integral role in the nursing shortage as new nurses must be educated to take the place of an aging licensed registered nurse population.
The study was designed to explore the factors students identified as reasons for not sustaining until program completion and their correlation to what faculty perceived as barriers to completion for nursing students. With this information, an added goal of this study was to identify possible best practice solutions to reduce attrition among nursing students in Georgia (Simplicio, 2019).
There is a growing shortage of qualified nurses. To continue to combat the shortage of capable registered nurses, nursing programs must acquire and retain students until full completion of the program. On average fifty-eight percent (58%) of high school graduates enter college each year and less than forty percent (40%) of them complete their degrees as planned (Thompson, 2018). In 2010, the Institute of Medicine (IOM) issued a report stating that by the year 2020 at least eighty percent (80%) of the registered nursing population would have at least a Bachelor of Science Degree in Nursing (BSN) at the entry level (Orsolini-Hain, 2012). The reality is that progress toward 80% of registered nurses having a BSN has been made, but it is still short of the goal. It is speculated that the 80% target may be accomplished by 2029 (Thew, 2019). Community and Technical Colleges currently provide the majority of the registered nursing workforce throughout the nation making attrition and retention a hot topic for discussion for Associate of Science in Nursing (ASN) programs. If retaining students for two years is a problem, surely four-year colleges and universities are seeing similar if not higher attrition rates.
The research revealed a number of factors that are related to the climbing rates of attrition in ASN programs. Stress and anxiety can play a role in high attrition and low retention at the collegiate level (Brussow & Dunham, 2018;Kukkonen et al., 2016;Li et al., 2015). The anxiety that looms while learners are actively in nursing programs can intensify as they progress to the end of the required coursework and begin to prepare for Health Education Systems Incorporated (HESI) exit exams and subsequently the NCLEX-RN (Doyle et al., 2019;Li et al., 2015). HESI exams are administered throughout and at the end of many undergraduate registered nursing programs. HESI exams are intended to assist students in preparation for the NCLEX-RN and are often high-stakes exams that can serve to progress or halt nursing students in accredited nursing programs (Dreher et al., 2019). This leads to an increased mental burden on students and educators alike causing more anxiety. The anxiety within nursing programs has a direct effect on attrition rates as the stress of the HESIs and NCLEX-RN spills over into the coursework, impacting students' ability to fully concentrate (Dreher et al., 2019;Sears et al., 2015).
Another factor relative to stress and its link to high attrition in undergraduate nursing programs is the experiential learning practicums or clinicals as well (Lipsky & Cone, 2018). Nursing is a practice profession, making the clinical experience an implicit portion of the learners' educational journey. Clinical experiences are paramount to the success of the registered nursing student. Practical experiences coupled with gender and age have been recurrent themes that emerge when nursing student attrition is studied (McKeever et al., 2018). A mixed-methods approach to studying nursing student attrition exposed three themes relative to experiential learning experiences: ineffective placement organization, problematic journeys to placement, and disappointing clinical experiences. Although not the only reason, practice related problems consistently are listed as part of the reason retention rates in nursing programs remain low (McKeever et al., 2018). Other reasons for learners leaving nursing programs prior to completion include academic challenges, burden of life demands as well as educational demands, financial strain, negative experiences, lack of support, and illness or injury (McKeever et al., 2018). Another cause for high attrition is discomfort among gender minorities, including male students, feeling pressured by stereotypical gender ideals which, when coupled with isolation, prompt attrition (Ferrell & DeCrane, 2016).
As more and more colleges compete for higher numbers of admissions, many students with academic deficiencies are being admitted and permitted to enter various programs for which they are not academically prepared. One result of this behavior is high attrition and low retention. Research shows that over sixty percent (60%) of the nation's healthcare workers are educated in a community college program (Vedartham, 2018). The curriculum for those programs often if not always includes some component of an anatomy and physiology (A&P) course as a prerequisite for entry. The attrition rates in these course subjects may have a correlation to attrition in subsequent health sciences occupational programs of study (Vedartham, 2018). Studies show that close to half of all students that enroll in an A&P course do not persist to completion. The aim of community colleges is to appeal to non-traditional learners thus they must remain cognizant of the incidence of educationally and academically underprivileged students being admitted and predisposing their programs to at risk learners (Vedartham, 2018). Healthcare professions rely heavily on science and math, therefore retaining learners in the requisite A&P courses is paramount. An ex post facto study examined over two hundred former nursing students' records along with qualitative data from ten full-time faculty members, thirty new graduates, and forty-five directors of associate degree nursing programs. Findings asserted a link between performance in two pre-program biology courses and three components of the pre-admission test for nursing with high attrition (Vedartham, 2018). The analysis found various strategies to assist in improving attrition and retention in A&P courses that include learners taking an assessment test to evaluate readiness for the course. With this test atrisk learners are identified and required to take two preparatory biology courses along with a technology course prior to being allowed to participate in the required A&P course (Vedartham, 2018). The foundational knowledge gained from the pre-courses prepared learners for the rigor of the A&P classes. The study and positive results allowed the community college to obtain a grant to support the program by providing dedicated faculty as well as free tuition to the students for the pre-courses. The overarching result was over ninety-five percent (95%) of the learners who participated in the program were successful in the A&P courses (Vedartham, 2018). Success in core requisites is a precursor to successful completion of higher education programs of study (Chan et al., 2019).
When learners are unable to complete their programs of study it not only affects them, but the higher education institution as well. For the learner the impact can be financial as well as social. For nursing programs in general, when a student does not complete, it continues to intensify the already dire shortage of practicing nurses. This effect is multifaceted and universal as the ultimate concern is lagging patient/client care (Tower et al., 2015). The literature review suggests nursing is attracting more non-traditional, diverse learners with more intense needs than educational institutions are able to support, thus leading to non-completion (Ferrell & DeCrane, 2016). It was found that attending college for non-traditional learners is akin to culture shock as the learners come into the program ill-prepared for the workload. A study by Tower et al. (2015) examined nursing students in their initial semester and tracked them to find critical markers linked to attrition. Interventions such as early identification of at-risk students, effective orientation, and mentoring were among programs available to enhance the quality of the learning experience and lower rates of attrition. This study included two hundred twenty-three (223) first semester nursing students from one Australian University of which seventy-eight percent (78%) were full-time students. It was found that of the learners who studied full-time failure of at least one course was a predictor of attrition. The study afforded students with critical at-risk markers interventions including tutoring, increased orientation, access to blended learning opportunities, and the choice to study parttime. The result was a 3.25% increase in retention from the previous year before the interventions were implemented (Tower et al., 2015).

Materials and Methods
This qualitative method study was designed to gain insight concerning high attrition rates among ASN students in a Technical College. The study collected data via face-to-face and telephone interviews with students who were previously enrolled in the ASN program at the study institution. Moreover, in depth face-to-face and telephonic interviews were held with current ASN faculty to gain insight from the faculty perspective. The interviews were used to provide comprehensive information about the participants' experiences and viewpoints associated with the ASN program (Christenbery, 2017). IRB approval was obtained prior to collection of data.

Population and Sample
This study relied on voluntary participants who met the inclusion criteria. To be included in the study, student participants must have been actively enrolled in the ASN program at the research institution between 2015 and 2018. Also, to be included the learner must have failed to sustain through degree completion in the ASN program. The inclusion criteria for faculty participants included being an active faculty member in the ASN program within the timeframe of 2015 to 2018. The Technical College supplied the researcher with the contact information of previous nursing program students who met the research criteria. A letter was sent out to prior nursing students who meet the specified criteria via email or regular US postal mail from the researcher with a request to participate in an interview with the researcher. The potential population of students consisted of up to fifteen male or female students who met the research criteria over the age of eighteen. More qualitative data came from interviewing participating ASN faculty whose identification was made possible through the Technical College's faculty portal. The faculty also received a letter detailing the implications of the research study and upon their voluntary participation, interviews were scheduled. The faculty participant sample was comprised of up to twelve faculty members who met the inclusion criteria

Instrumentation
Interviews were used with students and ASN faculty who met the inclusion criteria. The guided interview questions were altered as necessary during the active interview process as the questions were used as instruments to assist in gathering insight into the ASN learner experiences as well as the faculty experiences with the ASN learners within the nursing program (Rudestam & Newton, 2015). The semi-structured interviews were completed orally face-to-face or via telephone and the researcher took notes of the responses during the interview.

Data Analysis
The data obtained from the interviews was analyzed to find patterns of meanings through the use of coding. A computer assisted data analysis software (CAQDAS) package was utilized called IBM Statistical Package for Social Sciences (IBM-SPSS). Once completed, any recurring themes were identified and interpreted. All results were shared with the host institution. Table 1 presents a descriptive analysis of student demographic and student related characteristics. Data indicated that the average student was 29.50 (SD=5.93, MIN/MAX=22-38) years of age, female (n=7, 70.0%), and of a White racial identity (n=5, 50.0%). Most students also held a highest degree of a diploma (n=4, 40.0%), was currently enrolled part-time (n=5, 50.0%) attended in the years 2017-2018 (n=5, 50.0%), and withdrew in the years 2017-2018 (n=5, 50.0%).  Seven semi-structured interview questions were asked to student participants to better understand "What influences students' ability to complete the registered nursing program in an Associate of Science in Nursing (ASN) Program at a Georgia Technical College?"

Variable
When asked "How did you find out about the nursing program?" The two most common themes were family or friends (n=5, 50.0%) and school in local area (n=5, 50.0%). These themes are reflected in the comments "From my spouse as she graduated from the college's PN program and she encouraged me to apply" and "Nursing has always been a goal and I started looking in my local area in 2013" respectively.
When asked "What attracted you most to this nursing program?" The most common response was location (n=4, 40.0%). One student commented "Location was the biggest factor for me." The most common theme reflected in response to "Describe how you felt when you made the decision to attend this nursing program" was "excited" (n=5, 50.0%). One student stated that "Excitement was the first feeling as I felt I could finally help my family which is Spanish speaking. I wanted to be able to help my culture and I was finally going to be able to do that." When asked "Once you were in the program, describe the methods for you to keep track of your progress" the most prominently mentioned was Blackboard (n=9, 90.0%), the learning management system used in the course. One student stated that they "lived on blackboard and bannerweb looking at grades and also listening to professors to see what was coming next." In regard to the question, "What type of guidance was available to you throughout the nursing program to help ensure your success?" instructors (n=10, 100.0%) was the overwhelming response. One student stated, "I can honestly say the instructors helped me a lot with extra guidance and resources." When asked "How were you able to manage going to school with your other life obligations for example home, work?" the most common response was that they were "unable to manage" (n=5, 50.0%). One student said "I tried to take it one step at a time: try to put the stress of it all aside. I really wasn't able to do that though." In response to "How flexible was the program in being able to meet your needs? Do have specific examples?" all student participants indicated that the program was "rigid and strict" (n=10, 100.0%). One student said, "There was a rigid class schedule with no deviations but it was beneficial for life scheduling."

Table 2 Descriptive Analysis of "What influences students' ability to complete the registered nursing program in an Associate of Science in Nursing (ASN) Program at a Georgia Technical College?" Themes Within the Qualitative Data Provided by Students (n=10)
Five semi-structured interview questions were asked to student participants to better understand "What do (ASN) students report as ways to address the causes of attrition at Georgia Technical College?" When asked "Did the nursing program or the faculty have any ways to help you be successful in your nursing courses?" the majority of students mention the program's instructors (n=8, 80.0%). One student mentioned that "The faculty had extra worksheets, very supportive of us, encouraged us to talk about it with others." In response to, "If you were having difficulty did the faculty reach out to you or did you have to reach out to faculty for assistance?" both directions of communication were mentioned equally (faculty, n=6, 60.0%; student, n=6, 60.0%). Faculty led communication was commented on by one student saying, "For the most part faculty did, but there was one class that did not and the main instruction was study more; it was not a focused response on you specifically," however another student said "The student had to reach out for the most part by setting up a meeting for them to work with us after class. I was never turned down for a meeting." In response to, "What other types of support were available to you?" the predominant theme was scholarships or financial aid (n=6, 60.0%). One student said, "Financial Aid for me and I had no out of pocket expense for school." When asked, "What do you feel is your major reason for leaving the program?" the most prevalent theme was HESI (n=6, 60.0%). One student commented "HESI Examination -the 2 attempt and done approach. HESI writes your fate. HESI retakes were often in the same week which left little to no time for preparation." In response to "What support or services do you recommend to help students like yourself sustain in the nursing program until completion?" the most common theme was HESI as percentage (n=4, 40.0%). A student described "If HESI was actually a percentage of the grade and not the end all catch all."

Descriptive analysis of faculty participants
Demographic and professional characteristics of faculty participants was obtained and analyzed ( Six semi-structured interview questions were asked of faculty participants to better understand the question "What do ASN program faculty perceive as reasons for high attrition and low retention of ASN program students at a Georgia Technical College?" When asked "Tell me little about yourself and why you chose to become a nurse educator," the most common theme was had worked as educational staff (n=3, 42.9%). For example, one faculty member reported "I had worked in Long Term Care for years and did a lot of teaching with staff and was told by them that I was a good teacher. When I returned to school to get my MSN my project led me to being an educator because I worked with a program for family connections. I became a Parent Educator on drug abuse and addiction and then I got the job here." In response to "What do you think are the best methods to recruit students for the ASN Program?" the majority of faculty reported word of mouth (n=4, 57.1). For example, one faculty member reported "I think they hear about how fast they can complete the program and that is a big incentive as they want to make a good income fast." When asked, "Describe what you have done to mentor ASN students?" most faculty described Rapport (n=4, 57.1%). One faculty member said "Taking a personal interest in the students. Providing individual assistance in class. Building an official relationship with each student. Also helping them to see the light at the end of the tunnel." In response to "Describe what you do to ensure success with your students?" the most common response from faculty was Mentoring (n=4, 57.1%). One faculty member said "Meet 1:1 with at risk students to show them things that would be helpful for them to work on. Also have them complete the form after a test to make them accountable to acknowledge areas of weakness." When asked, "What programs are offered by the college to help student be successful?" most mentioned the Tutoring Center (n=5, 71.4%). One faculty member said "The tutoring center, but it only has English and Math tutors, I think. Also, advisement." In response to "Have you noticed any areas where students were seeking support and they were not able to find it?" responses were varied financial (n=2, 28.6), full faculty support (n=2, 28.6), and no areas needing support (n=2, 28.6). Three semi-structured interview questions were asked of faculty participants to better understand the question "What do ASN program faculty report as ways to address the causes of attrition at a Georgia Technical College?" When asked, "What do you perceive as the major reason(s) students fail to complete the ASN program?" the two most common themes were life issues (n=4, 57.1%) and lack of preparation (n=4, 57.1%). In describing "life issues" one faculty member said "Personal issues -our current student population has a lot of life matters that impact them like finances and them having to work to support a family. Lack of study skills, lack of proper training for instructors" while another faculty member describing "lack of preparation said "Many of the students are not prepared educationally. They have been spoon-fed the education up to now and passed on. Also, many are not prepared mentally for what it takes to get through nursing school. Family life such as divorce and also they are often the primary caregiver and only income provider." In response to "Can you tell me some of the experiences that you have had with students who have eventually left the program?" faculty were equally split between positive experiences (n=3, 42.9%) and negative experiences (n=3, 42.9%). One faculty member describing a positive experience said "When it is obvious that they are not going to be successful; taking time to talk to them and one in particular who came back some time later to thank me for guiding them to another career path that they had been successful in and happy in that career." Another faculty member describing a negative experience comment "I have had a lot: unfortunately, the negative ones stick out. I have had a couple military students who suffered from PTSD and one in particular got really angry at me and kicked the door. He was kind of used to being in charge and did not want to take instruction. A lot come into the program and say that it is more than they expected." When asked, "What methods of support do you think would help to decrease attrition and increase retention?" the most common theme was a Tutor (n=3, 42.9%). One faculty member said, "Perhaps have a dedicated nursing tutor; smaller class size to allow for more 1:1 assistance; and also, maybe a 'better' selection/filtering process for admission."

Conclusions
There is a concerted effort among stakeholders to include institutions of higher learning, healthcare organizations, and society to provide a suitable nursing workforce to meet the demands of the population worldwide. Because community colleges provide the majority of the entry level registered nurses, it is imperative that they along with other shareholders join forces to combat high attrition and low retention in nursing programs (Aulck & West, 2017; Harrell & Reglin, 2018; Tamari et al., 2020). The primary objective of this basic qualitative study was to ascertain student and faculty perspectives as to the causes of high attrition and low retention in undergraduate nursing programs of study. The study further proposed to discover best practice methods to curtail high attrition and low retention rates at the research institution. The information garnered from the study has the potential to positively impact attrition not only at the research institution's nursing program, but at nursing and multiple allied health programs throughout South Georgia.
High attrition and low retention are not new phenomena in higher education (Turner & McCarthy, 2017). Prior research has identified multiple factors that contribute to these alarming rates across all programs of study. The research concluded that stress, coping, anxiety, and lack of coping skills affect students' ability to learn and contributes to elevated attrition rates (Labrague et al., 2017;Turner & McCarthy, 2017). Registered Nursing programs are not unlike any other higher education program with its experience retaining students to program completion. As nursing tries to maintain its standards as an esteemed profession, students' abilities to sustain until graduation continues to wane. High attrition and low retention in nursing programs has remained problematic which has a detrimental effect on completion rates and in due course the supply of nursing professionals to meet the demand in the workforce (Peruski, 2019). Technical and community college nursing programs have attempted to answer the call to produce a practicable nursing work force; however, high attrition and low retention Consistent with prior research, this study supported all of these previous reports. The current basic qualitative study substantiated many of the previous findings but shed light on some methods that the research institution had not attempted that might prove beneficial in lowering attrition rates in the ASN program. The primary theme that was recurrent in both student and faculty responses was the presence of a tutor in the tutoring center that would be specific for health sciences and nursing majors (Tower et al., 2015). Students and faculty both agreed that a formal faculty-student mentoring program could help in the research institution's quest to improve students' capacity to complete the ASN program (Bice, 2018;Ingraham et al., 2018;Tower et al., 2015). The most recurrent theme from students regarding their major reason for having to leave the ASN program was the inability to make the program required score on the high stakes course final exams, the HESIs. The students did not feel that the HESI should be taken away, but that it should only count a specified percentage of their final course grade. Conversely, no faculty respondents reported the HESI as a major reason for students failing to sustain in the ASN program (

Data Availability (excluding Review articles)
The qualitative data supporting the findings of this study were gathered from a Technical College in Georgia. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conflicts of Interest
There are no conflicts of interests.

Funding Statement
There was no funding attained for this research.