Introduction

Attrition of students at all levels of nursing programs has received considerable attention in the literature. Although the research suggests a global prevalence, exact rates are unknown, primarily due to the inconsistent definition of attrition across studies.1 Attrition rates are reported to range from 10% to 50% in Australian, Canadian, British and American nursing programs,2-8 and rise as high as 85% for ethnic minority students.9 Definitions of attrition include but are not limited to voluntary withdrawal, dismissal due to academic shortcomings, failure to graduate, changing a declared major, or falling out of synchrony or "off track" from an entrance cohort. The causes of attrition are multifactorial, and rarely, in an individual case, will a single cause of a student leaving or falling behind in a program be identifiable.5-10 The cumulative effect of various academic, personal and social factors contribute to a student's desire to withdraw or inability to graduate.11 Additionally, the clinical practice focus of nursing programs has been shown to have an effect on attrition. Eick et al.1 noted that 39% of students acknowledge that their clinical placement experiences made them consider leaving.

Regardless of the reason for failing to complete a program and graduate, attrition rates have an individual, educational and professional impact. Inability to complete a program takes an emotional, social and financial toll on the individual affected student.2 High attrition rates also create a tremendous cost burden on educational institutions,12,13 which limits the number of students that can be admitted each year.

Admission and graduation rates ultimately affect the supply of nurses for the workforce. Therefore, attrition cannot be relegated to an individual or educational problem alone. Retention of students in nursing programs has been repeatedly cited as a concern for its potential impact on the worldwide nursing shortage.2,6,8,14 While research on attrition continues to provide an important understanding of why students fail to complete a program, more research is required to explore the related concept of student retention. In order to reduce attrition rates, educational institutions must develop strategies to retain the students in their programs.

Numerous theoretical perspectives have been presented, attempting to provide an organizational structure to the causes of student attrition. Vincent Tinto's frequently cited longitudinal model of departure15-17 establishes the critical importance of a sense of community, academic integration and institutional social-environmental contributors to the persistence and retention of students. Persistence is influenced through the mutually interdependent social and academic systems of the college, both of which have formal and informal mechanisms for student program completion. According to Tinto, students need to succeed in both the social and academic systems to increase their program success.

Tinto's model has been adopted in nursing by numerous scholars.5,18-20 His work asserts that the social and academic systems of the institution influence student integration and reinforce student persistence.15-17 Tinto conceptualizes integration as students' perceptions of their involvement in the life of the college through interaction with peers and faculty for both social and academic purposes. Mechanisms for integration are both formal (interactions with faculty/staff and other institutional experiences) and informal (extracurricular activities and peer group interactions, including study sessions). Social integration is related to interactions and affiliations outside the classroom, while academic integration is associated with the student's perceived connection to the intellectual domains of the institution. Students are more likely to persist if they have a sense of both social and academic integration into the institution. Intuitively, we would expect high performing students to consistently stay and low performing students to be at higher risk of leaving; however, some academically strong students leave before graduating and many students who struggle academically persist. It is possible for students to feel integrated in the social system without feeling integrated in the academic system and vice versa.16 Common sense would suggest that perceived integration within a program may contribute to continued persistence in the face of other personal and academic challenges,1,12,18,19 and accordingly, many organizations develop strategies to enhance integration. To date, there has been no synthesis of the various strategies that have been used in nursing programs to target integration of students for the purposes of retention, and therefore the question as to the types of strategies and their effectiveness remains.

While the focus of this review will be on integration strategies and their effectiveness in retaining nursing students of all backgrounds, the concept of retention has been identified as a priority need for minority students. Students of Indigenous,21-27 African American,19-28 Hispanic29 and immigrant cultures30 are the most frequently studied, given their disproportionately high attrition rates. Many of the strategies discussed in the literature to target integration of students focus on these minority populations. Thus, it is critical that their specific needs are acknowledged. Students from these populations, particularly in North American and Australian settings, critique their programs for their lack of attention to cultural issues and ethnocentrism.19,24,25,27 Minority students often have compounding disadvantages beyond culture, including poverty and first generation university status, which have been associated with integration. To address the cultural needs of Indigenous learners, Anonson21 reported on a unique partnership with 11 community, governmental and educational institutions coming together to support Indigenous and Northern nursing students in Saskatchewan, Canada. The strategies provided student and family support, mentorship, one-on-one coaching, Indigenous language classes and cultural events, which created a nurturing learning environment through a holistic approach. In a second example, Gardner30 implemented both formal and informal strategies for their immigrant population of East Indian nursing students, which included hiring a retention coordinator who was also responsible for advising faculty about cultural competence. They also developed a mentorship network, initiated family nights and offered support group meetings.

Many of the strategies targeting integration of nursing students focus on formal environmental supports such as academic advising, mentorship programs and peer supports. Numerous publications suggest the development of informal peer interaction and support interventions5,14,31,32 or formal mentorship programs to help assist with retention,25,27,29 and fostering peer relationships is important for immigrant students transitioning into a new cultural context.30 Integrating informal relationship building into programs has also been cited as contributing to student success and thus is a target area for interventions.10 For example, Stokes33 implemented gatherings during lunch to assist with maintaining regular contact with minority and international students. Gatherings acted as informal student-student and faculty-student support as well as allowed for easy identification of areas where the faculty could intervene in student integration.

Student retention has also been associated with faculty support and interest in student success,32 whereas a lack of support from the faculty can have a negative impact on students' motivation to successfully complete their program.11 Faculty and formal institutional supports can build on intrinsic student perseverance,34 but also must be appropriate for individual students. For minority students, it is important that faculty are supportive as well as culturally sensitive to prevent and counter any intentional and unintentional discrimination,28 as well as to determine cultural barriers and needs.30 Culturally sensitive supports must therefore be developed from an institutional to individual level.28 For example, Valencia-Go35 described a formal multifactorial support system, which provided faculty mentorship and faculty development for working with culturally diverse students.

The body of literature exploring the causes of attrition or the characteristics of persistent students is vast; however, less has been published exploring specific social and academic integration strategies aimed at increasing retention of students in nursing programs. To prepare the introduction to this protocol, CINAHL, ERIC and PsycINFO were searched in order to gain a sense of the nature of the retention strategies that have been discussed descriptively and/or evaluated via formal research. No systematic reviews were identified that attempted to summarize the various social and academic integration strategies described in the literature as targeting an increase in retention in nursing programs. One narrative review by Mooring5 was located and limited itself to summarizing recruitment, advising and retention programs identified in two databases (CINAHL and HealthSource). Therefore, a scoping review protocol is proposed36 aiming to examine and map the various formal and informal social and academic integration strategies that have been used to influence student persistence, increase retention and prevent attrition in nursing education.

Inclusion criteria

Participants

The review will examine studies and papers that have addressed social and academic integration strategies for undergraduate nursing students and/or the faculty that teach and interact with them, regardless of age, level in program or ethnicity.

Concept

The central concept investigated in this review is social and academic integration. The focus will be on integration strategies which have been implemented for the specific purpose of increasing student retention. The strategies may be social, academic, environmental, peer or faculty focused. They may include, but are not limited to, targeting issues of cultural diversity, clinical practice, classroom learning, academic supports, social support, peer support, mentorship, student-faculty relationships, student-student relationships and sense of belonging

Context

The strategies will be situated in nursing education programs worldwide. The programs of interest will include associate degree, diploma, Baccalaureate, and accelerated Baccalaureate nursing programs located in university or college environments.

Types of studies

This scoping review will consider all quantitative and qualitative primary research designs that incorporate a thoroughly described retention strategy targeting social or academic integration of nursing students. While it is anticipated that most of the quantitative studies will be descriptive in nature, both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies, will be considered. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies, will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. Qualitative research studies will consider all methodologies in the interpretive or critical paradigms inclusive of descriptive qualitative studies. It is anticipated that the majority of papers describing social or academic integration strategies will be descriptive in nature and implemented outside of a research context. These papers will also be included. For pragmatic reasons, and due to lack of translation resources, only papers published in English will be included. Papers published since 1998 will be included. The late 90 s corresponds with the evolution of nursing education to a competency-based focus and the shift of many nursing education programs into the university environment.37-40 Additionally, choosing 1998 as a start date ensures capturing papers that identify student retention in programs as a solution to the global nursing shortage, which has been identified as reaching a crisis around the year 2002.41

Methods

Given the diversity of possible strategies in the social and academic domains and the lack of empirical studies located in a preliminary literature search, a scoping review was chosen as the review methodology in order to capture the various strategies reported in the literature through all reporting options. Scoping reviews are beneficial when the intent is to map the available evidence on a topic. This scoping review will thematically analyze the types of social and academic strategies described in the literature, identify gaps, clarify key concepts and report on any evaluative evidence that may exist, in order to inform nursing program policy.36 Thus, quantitative research evaluating a strategy, qualitative research describing the lived experience of a social or academic integration strategy and descriptions of educational innovations implemented in a local context but not evaluated for effectiveness will all be considered relevant data to increase our understanding of the various strategies possible in the social and academic integration domains.

Search strategy

The search strategy will aim to find both published and unpublished studies from January 1, 1998 to December 31, 2018. An initial limited search of CINAHL and MEDLINE has been undertaken, followed by analysis of the text words contained in the title, abstract, and the indexed subject terms. This preliminary search informed the development of a search strategy which will be tailored for each medical database. A full search strategy for CINAHL is detailed in Appendix I. The databases to be searched include: CINAHL, ERIC, PsycINFO, and MEDLINE. Google Scholar will also be searched in order capture any additional sources outside of these four key databases.

It is possible the research review team will discover additional keywords during the examination of selected studies. If necessary, the database searches can be run iteratively with any newly discovered terms. Additionally, the bibliographies and reference lists of the selected studies will be hand searched to be certain all items were captured.

Information sources

The search for unpublished studies, guidelines and reports will include: major international health technology agencies, nursing professional associations and nursing colleges, as well as a focused Internet search using Google. ProQuest Dissertations and Theses Database (PQDT) and Theses Canada Portal will be searched for dissertations and theses. Relevant theses and dissertations will only be included if they do not require a fee to obtain the full text. Google and Google Scholar will be searched using keywords such as: retention, dropout, attrition, persistence, nursing student, undergraduate nurse, student nurse, minority nurse, peer support, nursing program, program completion, graduation, social integration, and academic integration.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote VX8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final scoping review report. As a scoping review is the chosen method of review and a large number of discussion papers are expected to form the data, critical appraisal of included papers will not be performed. However, if a strategy is well described in a research context and has undergone a formal evaluation, this will be noted in the charting table and will be highlighted in the narrative organizing the results for the completed review. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.42 Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool available in JBI SUMARI by two independent reviewers.36 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific study objectives. Papers describing social and academic integration strategies outside of a research context will have data extracted including strategy, population and context. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Studies and discussion papers where the strategy is not thoroughly detailed may be excluded. Authors of papers will be contacted to request missing or additional data where required.

Data presentation and synthesis

Tables and diagrams will be used to describe the synthesis of the results of this review. The results will be charted through an iterative process whereby the content of the charting table will be continually updated through addition or deletion of columns as is identified during the data extraction phase.36 Please see Appendix II for a draft charting table which will be used to present the results of the review. A narrative synthesis will also be included.

Acknowledgments

The authors would like to acknowledge the valuable assistance and advice provided by Ms. Kerry M. Macdonald, Library Director, Red River College, in the initial planning stages of preparing for this review. The authors would also like to thank Dr. Christina Godfrey from the Queen's Collaboration for Health Care Quality: a Joanna Briggs Institute Centre of Excellence for her valuable feedback on an earlier draft of this manuscript.

Funding

This review protocol was funded by the Red River College Nursing Department Research and Scholarship Grant. With the exception of LP, this team is employed by the funding department which is collectively interested in the results of this review as they pertain to increasing the retention rates of their own students. CEB was employed with the funding department at the start of the review but has since changed employment. The department named will not financially gain from the funding provided for this research.

Appendix I: Search strategy

Database: CINAHL Plus with full text (via EBSCO)

Limits: English language; January 01 1998 - December 31 2018

Search statement:

(Concept 1 OR Concept 2) AND Concept 3 AND Concept 4 AND Limits

Concept 1: Undergraduate nursing students

(MH "Students, Nursing+") OR (MH "Students, Nursing, Practical") OR (MH "New Graduate Nurses")

OR

TI (("student nurs^*") OR ("freshman nurs^*") OR ("undergraduate nurs^*") OR ("under graduate nurs^*") OR ("baccalaureate nurs^*") OR ("sophomore nurs^*") OR ("nursing student^*"))

OR

AB (("student nurs^*") OR ("freshman nurs^*") OR ("undergraduate nurs^*") OR ("under graduate nurs^*") OR ("baccalaureate nurs^*") OR ("sophomore nurs^*") OR ("nursing student^*"))

OR

TI ((student^*) OR (undergraduate^*)) AND ((nurs^*) OR (nursing))

Concept 2: Nursing programs

(MH "Education, Nursing+") OR (MH "Schools, Nursing") OR (MH "Curriculum")

OR

TI (("nursing college^*") OR ("nursing program^*") OR ("nursing school^*") OR ("nurses college^*") OR ("nurses program^*") OR ("nurses school^*") OR ("nurse's college^*") OR ("nurse's program^*") OR ("nurse's school^*"))

OR

AB (("nursing college^*") OR ("nursing program^*") OR ("nursing school^*") OR ("nurses college^*") OR ("nurses program^*") OR ("nurses school^*") OR ("nurse's college^*") OR ("nurse's program^*") OR ("nurse's school^*"))

OR

TI ((educat^*) OR (program^*) OR (train^*) OR (teach^*) OR (school^*) OR (undergrad^*) OR (degree^*) OR (diploma^*) OR (practicum^*) OR (curriculum)) AND TI ((nurse^*) OR (nursing))

OR

AB ((educat^* OR program^* OR train^* OR teach^* OR school^* OR undergrad^* OR degree^* OR diploma^* OR practicum^* OR curriculum)) AND AB ((nurse^*) OR (nursing))

Concept 3: Attrition/retention

(MH "Student Dropouts") OR (MH "Student Retention") OR (MH "Academic Performance+")

OR

TI ((dropout^*) OR ("drop out^*") OR (attrition^*) OR (retain^*) OR (quit) OR (quitting) OR (graduat^*) OR (convocat^*) OR (persist^*))

OR

AB ((dropout^*) OR ("drop out^*") OR (attrition^*) OR (retain^*) OR (quit) OR (quitting) OR (graduat^*) OR (convocat^*) OR (persist^*))

Concept 4: Social integration

(MH "Remedial Teaching") OR (MH "Social Inclusion") OR (MH "Support, Psychosocial") OR (MH "Social Participation") OR (MH "Transitional Programs") OR (MH "Mentorship") OR (MH "Faculty Role") OR (MH "Faculty-Student Relations")

OR

TI (("social integrat^*") OR ("academic integrat^*") OR ("study group^*") OR (mentor^*) OR ("extra curricular") OR (tinto) OR (tinto's) OR (remedia^*) OR ("peer tutor^*") OR (socialization) OR (socialisation) OR ("peer to peer") OR ("supportive environment^*") OR ("supportive learning"))

OR

AB (("social integrati^*") OR ("academic integrat^*") OR ("study group^*") OR (mentor^*) OR ("extra curricular") OR (tinto) OR (tinto's) OR (remedia^*) OR ("peer tutor^*") OR (socialization) OR (socialisation) OR ("peer to peer") OR ("supportive environment^*") OR ("supportive learning"))

OR

TI ((lunch^*) OR (meal^*) OR (dining) OR (dinner^*) OR (break) OR (breaks) OR (coffee) OR (breakfast^*) OR (fun) OR (sport^*) OR (walk^*) OR (exercise^*) OR (leisure)) AND TI ((program^*) OR (initiative^*) OR (peer^*) OR (group^*) OR (social^*))

OR

AB ((lunch^*) OR (meal^*) OR (dining) OR (dinner^*) OR (break) OR (breaks) OR (coffee) OR (breakfast^*) OR (fun) OR (sport^*) OR (walk^*) OR (exercise^*) OR (leisure)) AND AB ((program^*) OR (initiative^*) OR (peer^*) OR (group^*) OR (social^*))

OR

TI ((faculty) OR (teacher^*) OR (professor^*)) AND TI ((outreach^*) OR (support^*) OR (role))

OR

AB ((faculty) OR (teacher^*) OR (professor^*)) AND AB ((outreach^*) OR (support^*) OR (role))

Appendix II: Charting table

References