Vocation, Friendship and Resilience: A Study Exploring Nursing Student and Staff Views on Retention and Attrition
Graham R. Williamson*, Val Health , Tracey Proctor-Childs
Identifiers and Pagination:Year: 2013
First Page: 149
Last Page: 156
Publisher ID: TONURSJ-7-149
Article History:Received Date: 12/6/2013
Revision Received Date: 13/9/2013
Acceptance Date: 13/9/2013
Electronic publication date: 14/10/2013
Collection year: 2013
open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.
There is international concern about retention of student nurses on undergraduate programmes. United Kingdom Higher Education Institutions are monitored on their attrition statistics and can be penalised financially, so they have an incentive to help students remain on their programmes beyond their moral duty to ensure students receive the best possible educational experience.
to understand students’ and staff concerns about programmes and placements as part of developing our retention strategies.
This study reports qualitative data on retention and attrition collected as part of an action research study.
One University School of Nursing and Midwifery in the South West of England.
Staff, current third year and ex-student nurses from the adult field.
Data were collected in focus groups, both face-to face and virtual, and individual telephone interviews. These were transcribed and subjected to qualitative content analysis.
Four themes emerged: Academic support, Placements and mentors, Stresses and the reality of nursing life, and Dreams for a better programme.
The themes Academic support, Placements and mentors and Stresses and the reality of nursing life, resonate with international literature. Dreams for a better programme included smaller group learning. Vocation, friendship and resilience seem instrumental in retaining students, and Higher Education Institutions should work to facilitate these. ‘Vocation’ has been overlooked in the retention discussions, and working more actively to foster vocation and belongingness could be important.
International concern about retention of student nurses who begin undergraduate programmes is widespread [1-3]. Why students leave is complex and multifaceted, with rarely just one reason responsible for non-completion [1, 4, 5].
As Higher Education Institutions [HEIs] in the United Kingdom are monitored on their retention and attrition statistics and can receive financial penalties if these are excessive, there is a focus on how students can be enabled to remain on their programmes of study [6, 7]. Areas including financial difficulties, family commitments, unpleasant placement experiences, and academic requirements are frequently cited as being responsible for attrition [8, 9].
A mix of personal and programme reasons  operating at various levels  determine why students leave. Staying is related to the extent of support that students receive, including family , friends and peers, and academic staff [2, 11]. Financial hardships may be a crucial determinant on students’ leaving, but personal resilience and determination to succeed can overcome this . Nearly half of all students considered leaving their course in a large regional study of healthcare students in the United Kingdom  and this is similar to non-healthcare students, where up to 42% consider leaving . Other aspects that are particularly challenging for healthcare students are the level of academic demands encountered [10, 13], the ‘reality shock’ of practice experiences  for those with no previous nursing background , feeling unvalued, unmet expectations and stress . Leaving usually takes place in the first year of the programme  and being older is associated with staying . Poor clinical placement experiences inform decisions to leave [3, 16] and mentoring is formative in the perception of placement experience .
The international evidence-base on student nurse recruitment and retention has developed since Glossop et al.  and Gaynor et al.  remarked that there was a lack of systematic evaluation of the issues from students’ perspectives; and international studies have subsequently attempted to describe and quantify these factors [8, 6, 11, 17, 20-22]. There are now also several well-conducted systematic reviews of the literature which inform the evidence-base [1-4]. Cameron et al. [1, 2] have identified from the literature reasons why students stay , and reasons why they leave . They note that retention studies are fraught with methodological problems, including data inaccuracies and low response rates, but believe that leaving early may be attributed to students’ failure to understand nurses’ roles, leading to dissatisfaction with programmes, whilst attrition later in programmes may be attributed to a combination of personal factors that culminate in a personal crisis . Concerning reasons for staying, personal commitment and good support are essential, although 'support' is rarely explicitly defined and identification of failing students is problematic. Partnership between students, placements and HEIs requires strengthening to ensure that support is optimal . For Unwin et al.  attrition is a complex phenomenon but central is the concept of engagement or lack of it for students, as this influences retention, particularly when allied to personal and organisational factors. In 2012 Eick et al.  also found poor quality reporting of retention and attrition studies still to be an issue in the literature, but that studies investigated personal reasons for leaving, demographic factors, and students' attributes. There was no single reason (related to placements) why students chose to leave, but being a young or a male student were major factors, along with being exposed to unpleasant placement experiences, the attitudes of placement staff, and lack of support. Perceptions of the nursing profession and practice assessments were also factors in placement-related attrition.
Improved pastoral support and consideration of a wide variety of supporting activities and behaviour are recommended to help students stay [4, 8, 11, 13], with ‘belonging’ a crucial concept in understating why they stay  and specific university welcoming’ activities noted as useful on entry [12, 23].
It is in this context that we designed our study to investigate the issues facing our students, how we could better foster a sense of belonging and suggest what we could do to alleviate their concerns and help them to stay. It is only recently that literature records processes and support offered to students [12, 20], rather than making recommendations based on research, and we sought to understand students’ and staff concerns as part of developing our retention strategies. It is clear that students and staff have differing perspectives on student support and we sought to get a fuller picture of the issues by including both sets of stakeholders.
To understand students’ and staff concerns about this pre-registration nurse education programme and placements as part of developing our retention strategies.
MATERIALS AND METHODOLOGY
This paper reports qualitative data on attrition and retention gathered as part of an action research (AR) study. AR is a process of inquiry used to investigate issues by direct involvement with those experiencing them, to develop solutions based on collaborative, democratic processes and active participation by those involved. AR is a sequence of events and an approach to problem solving which contributes to knowledge and understanding  which can embed change within organisations . We were mindful that personal motivation and aspiration were important to student nurses , and wanted to engage them in designing the future for their colleagues, and so we used Appreciative Inquiry [AI]  as a guiding principle of study design and data collection. AI uses a four stage process involving discreet but interconnected phases of Discovery, Dream, Design and Delivery , with data collection taking place in face-to-face and virtual focus groups, and individually, for the Discovery and Dream elements, and a Steering Group for the Design element. The study was designed and conducted as an action research study, however this article reports qualitative findings from these initial three elements, and so the Delivery phase will be reported separately.
Recruitment and Sampling
Participants were recruited via School email addresses for current students and staff, and by post for ex-students. Key staff stakeholders invited to participate (n=38) were Nursing Programme Leaders, Recruitment and Marketing staff, and Placement Development Team members (PDT, our structure for practice-based support of students and their mentors). All (n=134) current third year student nurses from the adult field were invited. We also invited to a separate group (n=80) students who left their programmes early (‘early leavers’) between 2007 and 2012 (we did not ask those who were discontinued for academic and/or practice failure).
Data Collection and Analysis
We ran three separate focus groups, one with current adult field students, one with ex-adult field student nurses, and one with staff. To encourage participation from those living remotely from the main campus we ran two virtual focus group using live interactive webcasting with a secure web discussion board, and individual telephone interviews. The virtual focus groups were instigated based on our experience using this technology for teaching (Williamson et al. 2009), where we found webcasting acceptable to reach students in widely dispersed geographical areas.
A schedule of questions was agreed between the research team, based on common ideas from the literature (see Table 1), which ensured that the schedule of questions was established by the researchers to have face validity. They were made relevant to the different groups at each data collection event, meaning that the questioning made by the research assistant was slightly different but on similar lines and Table 1 is included to illustrate the areas covered. The questioning explicitly concerned factors that encouraged students to stay or leave, this was clear in the participants’ letters and the research assistant explained and reiterated this at the start of data collection.
Schedule of Questions Used in Data Collection
|•Academic issues & support
|•Individual Personal/family Circumstances
|•The reality of nursing life
|•Overall, what is keeping you here/made you leave?
|•Ideal situation: if you could dream or imagine the ideal situation for you personally, what would have helped you most over the course of the programme
All data were collected between Sept and Dec 2012 and were recorded and transcribed. Content analysis was undertaken emerged  to extract meaning from this body of textual data to draw inferences. Initially, codes were identified in the transcripts, and from there key themes and subthemes emerged . In order to maintain rigour, codes were generated from the data by two researchers, and themes compared and agreed following discussion. This is a key step in establishing the reliability, dependability and trustworthiness of qualitative research findings  and ensured that the results were not biased by the research assistant’s exposure to the students, or the principal investigator’s exposure to the literature and programme knowledge.
This paper reports qualitative data related to attrition and retention and the action plan will be reported separately as part of the Delivery phase of the AR study.
Ethical approval was gained from the Faculty Staff Ethics committee. Written consent was secured from all participants, with the consent form and participant information sheet available to participants in advance of data collection. Assurances were given that data would be used anonymously, that participants had the right to withdraw data at any time before publication, and that non-participation would have no adverse consequences for their employment or study.
Attendance at the focus groups was as follows: six current students attended one focus group with two at a virtual focus group; two ex-students attended another focus group, with a further single phone interviewee and a single attendee at a virtual focus group, and six staff at another focus group. One virtual focus group did not receive participation.
In total eight current students, four ex-students and six staff attended. Following these groups, a single mixed steering group combining these stakeholders (n=8) met in Dec 2012 to discuss and agree a strategy for service improvement in the form of an action plan.
Three of the research team were longstanding employees of the faculty, and two were in senior managerial positions, so in order to protect student and staff anonymity, and to ensure authentic data, we did not collect full democratic details of the sample, and the research assistant promised the participants that there would be no disclosures of personal information that might identify them to us. All the current students were third year student nurses who had undertaken a variety of placements in the acute sector as well as the community. Of these eight participants one was male. Of the ex-students, all four were female and had not reached their third year. Of the six staff, all except one was female and all were experienced in their roles, meaning that they had considerable career exposure to students and student support. Of these six staff, four worked full time for the university, and two were engaged in clinical support roles primarily in their NHS trusts with honorary contracts with the faculty. At the steering group, there were two current students (one male), no ex-students and four staff (none male). In addition, three members of the research team were present.
Four themes concerning reasons for staying or leaving emerged from the data: Academic support, Placements and mentors, Stresses and the reality of nursing life, and Dreams for a better programme.
Academic support was reported by students as being variable, with examples of supportive help with academic work but some examples where the students were dissatisfied with the quality and quantity of feedback they received about assignments. Where academic support was reported as being good, this was related to the students’ ability to ask for help. Informal peer support was noted as being important and useful in student retention by current students and staff. This was particularly the case where students had formed friendship groups with whom they shared information and supportive activities throughout the course.
Current student 1: [When you feel] ‘I really don’t want to do it now’ [complete the course], the only thing that will bring you back is your friends that are on the course.
Current student 2: ‘Oh you’re feeling the same, ok that’s nice’, so, there's two of us feeling [bad]. The amount of train journeys home me and [name] had and we’d be like crying, but laughing at the same time.
When friendship groups are not supportive students struggled academically.
Early leaver 1. I found people [other students] would ask you for help but they weren’t very keen on sharing their own ideas…they were very focussed on their own work.
Current students and staff mentioned as helpful the newly-instigated Peer Assisted Learning Scheme (PALS) in which second years provide support for first years. Staff noted that a sense of belonging was difficult to foster in a large campus with large student numbers, and the experience of nursing students was different from that of others because of the duality of academic life and clinical practice, with its unsocial hours and shift work.
Staff clearly identified that student support was dependent on their coming forward and engaging with university-level provision.
Staff member 1. Our students do get support from Learning Development [part of the University support structures with a remit to offer advice and guidance to ensure students are successful in their studies] in terms of essay writing skills and critical analysis and so on. Again it is something which is voluntary that they go and access or we suggest that they might like to. And interestingly Learning Development also say that a vast proportion of the students they get are nursing students.
Support for dyslexic students was an area where staff identified that the University excelled and if students would present for assessment a great deal of academic support was forthcoming.
Staff member 2. There’s confusion over the dyslexia versus academic ability…if you have that academic ability, the dyslexia support will make a huge difference. And you can adapt to that and find strategies to deal with that. If you are less able it is more difficult.
Whilst all students, early leavers and current, wanted more support, it seems as if the early leavers found the academic demands more bewildering and were more likely to feel intimidated by lectures, university and other students, and this contributed to negative feelings about leaving.
Early leaver 1. Some people were really academic [meaning studious].
Early leaver 2. Or just really knowledgeable about nursing because they had done care work for 20 years so they really knew all about it. And I had never done any so I just sat there and they were talking in depth about diabetes or something like that and they’d done this super human presentation in two hours. And you are like sitting there just feeling totally stupid, so you just like keep quiet and just don’t admit you haven’t got a clue.
Early leavers found it difficult to organise their study time or practice adequate time management, and had not accessed University level help to achieve this.
Early leaver 1. It was difficult for me, I think that’s something to do with time management. It ended up where I had left it maybe a little bit later than I should have done.
Current students noted that plenty of academic support was available.
Current student 3. There's lots of support in the library, it’s valuable. We have had a little part of a lecture each year where someone from the library has come in and talked to us about things like that, including time management.
Staff focus group participants also said that personal motivation and organisation were held crucial to students’ successfully completing the programme. The term resilience was used repeatedly by staff as a reason why some students stayed and others left. Lack of engagement, personality factors and lack of personal assertiveness contributed to poor academic performance.
Staff member 3. Certainly there are quite a number of students who don’t access the academic support which is available.
Staff member 4. And they are usually the ones who need it.
Staff member 1. [The poor students are] often the students who need you most who don’t turn up - forget to come to tutorials.
Some students and staff saw potential for Skype communications to overcome long distances and establish regular contact with their personal tutors.
Placements and Mentors
Current students discussed their experience of mentoring as variable in placements. Staff noted that the demands on practice mentors were high, and that clinical pressures and short staffing could explain the apparent unwillingness of some to carry out the role. Some students mentioned that some mentors did not seem prepared or willing to undertake mentoring.
Current student 1. You had to explain the [assessment of practice documents]. This is what we need to do. This is what this means. Like tell them what to do.
This apparent disorganisation in mentor allocation and availability could have consequences for students’ achievement of practice outcomes.
Current student 2. But I have had the complete opposite, I have had brilliant mentors all the way through. I have loved every single placement. And, they have not been the best placements but I have enjoyed them. I still keep contact with them all.
Students who had stayed on the programme said that there was something intrinsic about nursing work that kept them going when the academic side of programmes or the perceived lack of support from academic staff or mentors made them feel like leaving. Staff used the term vocation to indicate a quality of commitment to nursing that they believed persisted in today’s healthcare and HEIs.
Current student 4. Something that kept me on the course, not academia at all, it’s the patient side, being able to go out onto placement…last year I was privileged to see an organ retrieval from a patient that had passed away, it’s those sort of tasks you get to see... they humble you; you get to spend the last few hours with a patient’s life.
For early leavers, poor placement experience was the point at which they decided to leave, and was clearly a factor in their attrition.
Early leaver 2. I wasn’t happy in my placement and it got to the point I just couldn’t face going…I just thought, I can’t be bothered, and my car died, so I couldn’t get to my placement.
Early leaver 1. So that really put me off. The placement was fine, the residents were fine, quite a few of the nurses were really nice, but some of them, really put me off it. Like being horrible.
For these ex-students it would appear that the intrinsic or vocational aspects of nursing care were not sufficient to motivate them to succeed despite setbacks. They also seemed not to appreciate that their early placements provided a learning environment for fundamental nursing care, and they were unfulfilled in their work.
Early leaver 2. Then you start to think ‘Oh maybe they don’t think I am capable of doing a drugs round’. So then that knocks your confidence even more. Because you are thinking ‘Oh they aren’t getting me to do clinical stuff because they don’t think I can’. They are just leaving me doing like feeding or changing or what have you. Making beds, because you know, is that nursing?
Early exited students also discussed their lack of assertiveness in relation to placement mentors and would have liked some training in that respect, describing themselves as too timid.
Financial difficulties were related to travel to placements:
Current student 3. Financial things are a really big aspect of why people would leave, because some people just genuinely can’t afford to do it. And I know we do get quite a lot of support, we get out bursary and we get like travel refunded and you know whatever else but sometimes it’s just not enough.
Current student 5. It’s a real struggle, because if you don’t get a bursary then you don’t get your travel expenses paid. And when you are working at a distant placement and you are travelling 25 miles each way, each day, and you are not getting that petrol money paid back.
The concern from the staff focus group, which included university lecturers and PDT NHS clinical staff, was the need for strong mentors who would uphold standards in practice, and how PDT members routinely visited students in their placements to try to be proactive and identify issues of concern with students at the earliest possible opportunity.
Staff member 5. Problem mentors, we all have some, but I totally agree that they are definitely on the demise…we are whittling them out as we know about them and we just don’t use them.
Stresses and the Reality of Nursing Life
Students noted that the course could be all consuming, with little time for social life or other activities because of the academic and practice demands not experienced by other students, and that this had an impact on current students’ sense of belonging to the wider University community.
Current student 1. They call it a degree but it’s not. Like it’s a degree but... we are not really part of university life.
Nursing was discussed as difficult and occasionally upsetting, and on top of the academic demands the cumulative effect could be stressful.
Current student 1. [On the way home] you are explaining your day and you can’t believe [it] no other 19 year old had ever done this before, and you are laughing at it, but then we are crying because we are so stressed and tired.
Current students discussed their views of how students might be better prepared for the reality of nursing life before they started the course. It was acknowledged that it was difficult for teenagers to get experience of nursing work, but this was seen as potentially valuable to avoid ‘reality shock’.
Current student 4. You should have to do some sort of experience in health care before you come onto this course. ‘Cos the number of people that have left… they have said ‘I didn’t know what to expect.’
The reality of placements and being unprepared for their demands was discussed as a substantial part of the decision to leave by the early leavers which, combined with other experiences was the final straw.
Early leaver 1. You know it is going to be intense. I was ‘oh it will probably be a four week placement and another four week placement’, I didn’t realise it would be a six week placement followed by a 12 week placement. So that was me, not really looking into it.
Staff identified that students expectations of how the programmes would run was sometimes unrealistic and that that caused problems when the reality was understood, and this contributed to attrition.
Staff member 5. Some people maybe come into nursing with ‘rose-tinted glasses’, about what nursing actually [is like]…Then they get into placement and see nurses that are undervalued and underpaid and overworked and doing lots of things that take them away from patients, and maybe they are thinking ‘actually, is this something that I want to do?’ ‘This is not what I came in to do.’
Dreams for a Better Programme
Students mentioned better facilitation for academic and practice support in relation to how they wanted to change things for the better.
Current student 2. Come together in small groups, have discussions of any problems we’ve had on placement, any things we have had to deal with. And like, I want my lecturers to be empathetic with what I am going through.
Current student 4. With the fact that you get these sort of things, people dying is a prime example, and it’s not always peaceful, it can be very, very traumatic, to have this discussion group where every couple of weeks you could get together.
This role was noted as being usefully taken by a senior student, with a buddying relationship established in year one.
Students raised specific issues about being placed at long distances from their home, and were clear that the early starts had a detrimental impact on their ability to achieve in practice. Travelling long distances could even be dangerous
Current student 2. Oh there's a nice pull in [town named]. Like a place where the lorries go, I had a pillow and a blanket in my car, and I would pull over and sleep for half an hour because I couldn’t stay awake [after nightshift].
In common with other studies, our students and staff have discussed a number of issues indicating that decisions about staying or leaving nursing courses are complex and multifaceted, particularly regarding academic support, placement and mentors, finances and travel, and stress and the reality of nursing [1, 4, 5]. Similar to the literature, our students believed that friendship is an important determinant of their programme performance [8, 11] whilst lack of peer support and large cohorts has been noted as a factor in students’ isolation and lack of belonging : institutions that foster a sense of belonging generally retain their students more effectively than those that do not . The need to belong exerts a strong influence on thought processes, emotions, behaviour, health and happiness; without it people experience diminished self-esteem, increased stress and anxiety, depression and a decrease in general well-being. Nursing students’ motivation, self-concept, confidence and future career decisions are influenced by the extent to which they experience belongingness [30, 31]. Findings from this study suggest that friendship groups are important in building belonging, and where these are not strong, students are more inclined to leave. One issue mentioned in the theme Dreams for a better programme was having small groups, meeting regularly to debrief and share experiences, and this belief in the efficacy of small group work is reported elsewhere . These have been established at this university and others in the UK through the national PALS scheme, where second year students are trained to run informal support groups for first years. PALS can support placement learning, particularly for novice students, and has been demonstrated to reduce feelings of social isolation in clinical placements, helping them to cope with the challenges and reducing the factors associated with attrition .
Another factor in attrition is students not engaging with proffered support, and in this study early leavers reported not engaging, and were also less assertive in their outlook compared to those who stayed. Staff also strongly expressed the view that lack of engagement with available learning resources was important for those weaker academic students. It maybe that these early leavers who had not engaged with support had unrealistically low expectations of the academic demands of the programme, and that this disparity between expectations and reality are an element in their decision to leave [4, 13].
Personality factors have been shown to be important in retention, and while assertiveness is not frequently cited, self-efficacy, ability to cope with stress and emotional intelligence have been researched . Our staff used the term resilience to indicate a necessary feature of students’ personalities, that went beyond high motivation to indicate a ‘stickability’ when faced with nursing’s heavy challenges. Resilience has been identified as a complex characteristic of individuals encompassing the personal qualities that enable a person to thrive in the face of difficulty; it can be learned and is promoted by family bonds and external support systems, whilst qualities of personal resilience include the ability to seek others’ support, and optimism [33-35]. Resilience has been described as key aspect for health professionals as it enables them to adapt to and deal with high workloads, stress and rapidly changing patient care; arguably so important that it’s development should be a priority for students as it is linked to personal identity . High resilience has also been noted as essential in retention .
A unique finding from our study was that students talked about intrinsic rewards from patient contact and staff talked about vocation as a reason for staying. ‘Vocation’ means a strong personal belief that one has been called to carry out some specific occupation, having been chosen in some sense. It is frequently given religious connotations. A nursing vocation implies dedication to assisting another who is disadvantaged in some way and the nurse responds with personal virtues of compassion, care and concern . Having a ‘vocation’ or a ‘calling’ to be a nurse is a concept that has lost ground as nursing attempts a professionalising project and moves away from gendered  or religious  explanations of why people want to care for others. It may be that there is a tension between a previous view of student nurses as complaint and steeped in hospital ritual and tradition, compared to the questioning, critical thinking nurses that are the goal of modern university education , and thus relying on notions of vocation for retention may be counterproductive if this concept is not compatible with contemporary healthcare practice. However, forming a professional identity is important for student nurses, who are neophyte practitioners and a sense of calling maybe central to that , particularly as there is a strong expectation amongst the public that the values of compassion and care are still foremost for nurses . The concept of vocation and the application of these values are seen as a counterbalance to impersonal, mechanistic care ; successful students attempt to match these ideals.
Moreover, having a low sense of vocation is associated with predicting attrition , and this corresponds with our early leavers, who seemingly did not find that the intrinsic rewards of patient care overcame the many discomforts associated with placements, mentors and academic life. However, vocation does not appear in any of the systematic reviews of the literature [1-4] as important in attrition or retention and so it seems to have been overlooked recently as a motivating factor amongst student nurses.
Retention is rightly a serious concern for nurse education HEIs, and improving the student experience to help them to stay is laudable. However, some attrition will always be necessary because programmes leading to nursing registration must be able to discontinue students who cannot meet the appropriate professional standards. In the UK, the Nursing and Midwifery Council  has a statutory duty to regulate nurse education and standards for the profession, and lays down specific competencies to be achieved during programmes and at the point of registration. These are part of its duty to protect the public, and it is essential that HEIs adhere to these standards in pre-registration programmes, meaning that some attrition is necessary and can be seen in a positive light. Students may change their minds about their career choices and decide that nursing is not for them, and this can be viewed positively as the student can move on to a preferred occupation, leaving patients and clients to be cared for by nurses making active choices to continue their careers.
This was a small study in one university, with a sample size limited by lack of students volunteering to take part. Although we asked all the then-current students (n=134) to participate; only eight did so. It is particularly disappointing that only four ex-students (from a sample frame of n=80) decided to talk to us about their experiences and how these contributed to their decision to leave, however it is not surprising that more did not come forward as they have left the university and moved on to other things. The nature of the study means that all conclusions are necessarily tentative. We have, however, shown the extent to which our findings resonate with the international literature in the extent of linkages between our study data and existing literature in the discussion section.
RECOMMENDATIONS FOR FURTHER RESEARCH
As we found that friendship groups are important in retaining nursing students, further research should be conducted concerning how this can best be achieved. A template for interventions exists from the UK Higher Education Academy , and nursing HEIs could fruitfully implement and evaluate these. In addition, Eick et al.  found that young and/or male students were particularly at risk of early exit, as were those exposed to unpleasant placement experiences. Students in our study spoke about wanting more regular, small group and reflective-type activities, and it would be valuable to implement such strategies in nurse education  potentially targeted at risk groups, and this could be evaluated. It would be useful in this context to investigate the linkages between regular small group support, resilience and vocation. McDonald et al.  implemented a work-based educational intervention to develop personal resilience in qualified nurses and midwives, and this might usefully be extended to student nurses and outcomes evaluated. Part of any research programme in this area could include discussion of appropriate ethics and values in nursing care, as while it has been argued that there is a tension between a vocation for nursing and the critical acuity required in today’s university graduates , it is likely that the values of caring and compassion associated with nursing are also a part of students’ decision-making about why they want to pursue a career in nursing, and form part of their identity as they progress in their programmes: if a sense of vocation may predict attrition  then it makes sense for universities to try to instil vocational values, and interventions that do this should be researched.
Our study shows that our students have common concerns with others elsewhere, and the themes Academic support, Placements and mentors and Stresses and the reality of nursing life, resonate with international work . When asked about their Dreams for a better programme, students wanted more small group and reflective learning, and this has been implemented via the PALS project. Friendship groups are instrumental in retaining students and HEIs should work to facilitate these forming, as this would help to engender a sense of belonging amongst students, which is crucial to their achievement. ‘Vocation’ appears to have been overlooked in discussion about retention, and working more actively to foster a sense of vocation as well as belongingness could be important for student nurse retention. Further research is warranted on how vocation, friendship forming and resilience are linked and can be embedded in programme delivery .
Study design GW, VH, TPC; data collection GL; data analysis GL & GW; manuscript preparation GW, VH & TPC Conflicts of Interest
CONFLICTS OF INTEREST
The authors declare that they have no conflict of interest by any means with respect to this research manuscript.
Thank you to Gloria Lankshear who was research assistant on this project and collected and analysed data.
Plymouth University teaching Fellowship/PEDRIO scheme.