Prelicensure nursing programs are academically rigorous, and not every student progresses through the program according to the curriculum plan. Nursing students who fail and need to repeat a course to progress may delay their graduation and entry into the profession and experience personal consequences1 and are also at increased risk for attrition.2 Nursing student attrition is a global and perennial problem, causing individual costs, both financial and emotional, wasting academic resources when student failure leaves an opening that is not filled in the cohort model of education and contributing to the recurrent shortages in the nursing profession.3
Although there is concern and attention focused on students who drop out or stop during nursing school, repeaters are a hidden subgroup. Nursing schools publicly report student outcomes data but do not specifically report the incidence of repeaters; this population is included in the numbers of those who do not graduate on time and those who leave for any reason.4 Nursing student repeaters are a specific population that deserves attention: they have achieved the entry requirements for a nursing program and may have passed one or more nursing courses before failing. Unlike some students who withdraw from a program because they have decided that nursing is not a good professional fit, repeaters are students who know that they want to practice nursing and are committed to putting in more effort, including repeating a course. Repeaters are a population with great potential for success but may require different supports from other students who also struggle in nursing school.
When the literature is limited on a topic, such as the topic of nursing student repeaters, a scoping review is ideal to outline the information that does exist and identify areas in which more research is needed. Scoping reviews differ from other types of literature reviews in their broad approach. The Joanna Briggs Institute5 includes scoping reviews in their description of 10 types of systematic review processes, most of which are focused on collecting the best-quality research-based evidence. Scoping reviews aim to give an overview of a topic, without using quality of research as a limitation, and even include literature that is not peer reviewed, that is, gray literature.6 This scoping review was done with the purpose of summarizing the literature on nursing students who repeat courses to identify gaps in knowledge about this population.
This scoping literature review was guided by the methodology described by Arksey and O'Malley7 and expanded on by Levac et al.8 Arksey and O'Malley outlined 5 steps in their methodological framework: developing a research question (stage 1), collecting applicable studies (stage 2), choosing studies for inclusion (stage 3), extracting data from the literature (stage 4), and organizing, summarizing, and sharing the results (stage 5). The research question chosen to guide this review was “What is known about repeaters—nursing students who fail and repeat a course?”
Inclusion criteria included articles on prelicensure, also called undergraduate or preregistration, nursing students who had failed and then were required to repeat a course to progress academically. Considering the lack of literature on the topic, the types of literature for consideration were inclusive of discussion papers, editorials, and gray literature, as well as research-based articles, and the time frame for review was extended to the limit of the electronic databases, which was 1972. Literature about nursing students at risk for academic failure, those struggling but still academically progressing, and those who had already dropped out or been dismissed after academic failure were excluded. Literature about student populations that were already professionally licensed, for example, registered nurse to bachelor of science in nursing (RN-to-BSN) students, were excluded. Other exclusion criteria included articles published in a language other than English. The author then consulted with a librarian to identify keywords and develop the search strategy, using a concept map of the topic to guide this process (see Figure 1, Supplemental Digital Content, http://links.lww.com/NE/A617). The strategy for searching the literature included searching the electronic databases PubMed/MEDLINE, Cumulative Index to Nursing & Allied Health Literature, Educational Resources Information Center, and Conference Papers Index. In addition, the author conducted a hand search of the reference lists of included articles. The keywords used for searching the electronic databases included variations on the terms “nursing students,” “academic failure,” “academic probation,” “academic progression,” “academic persistence,” and “academic repetition.” In Figure, Supplemental Digital Content, http://links.lww.com/NE/A618, describes the process of retrieval of articles to review. The literature search was conducted in April 2018 and updated in August 2018.
In total, 3,094 citations were identified for review. Hand searching of reference lists of those meeting inclusion and exclusion criteria elicited 10 additional articles to consider. The abstracts of all search results were reviewed, and after application of inclusion and exclusion criteria and elimination of duplicates, 28 abstracts were identified for full-text review. After reading the full texts, 9 articles were eliminated: 6 did not meet the inclusion criteria, as they focused on academic failure and student attrition rather than repeating a course, and 3 were dissertations based on research that was shared in journal articles that were already included in the review. The final 19 articles included in the review consisted of 11 that were based on quantitative research, 5 that were based on qualitative research, and 3 that were not research based. The data from all of the included articles were summarized in a table (see Table, Supplemental Digital Content, http://links.lww.com/NE/A619). The results of the review are described by type of research methodology (quantitative or qualitative) or non–research-based articles.
There were 11 articles based on quantitative studies analyzed for this review. The articles were written over a span of time from 1991 to 2018 and included reports from the United States, Spain, and Iran. The research articles from the United States included 5 studies of associate degree nursing (ADN) students,9-13 3 studies focused on BSN students,14-16 and a study that collected data on all types of nursing programs in 1 state.17 The studies conducted in Spain and Iran were both done in university settings.18,19 Two articles, 1 quality improvement project10 and 1 experimental study,18 described the impact of interventions intended to support nursing student repeaters.
Nursing students repeating courses is an issue for all types of prelicensure programs. Repeating courses contributes to attrition and extended time in the program (longer time to graduation) and, thus, to wastage of resources such as openings in nursing programs, which tend to be cohort based.9,14,16,19
Two studies demonstrated that nursing students fail and repeat courses at a significant rate.17,19 One study, conducted in a single state in the United States, found that the rate of repeating in 1 year was 4% of annual admissions for public BSN programs and 13% for public ADN programs.17 The other study was conducted in Iran19 and reported that over an 18-year period at 1 university, there was a nearly 20% rate of course repetition.
Nine of the quantitative studies were retrospective, seeking to demonstrate the incidence of nursing student course repetition17,19 or to correlate course repetition and other factors with outcomes such as program completion or passing of the licensure examination.9,11-16 In 7 of the studies, nursing student course repetition correlated with poor outcomes: failure of another course,9 attrition from the program,11,15 and not passing the licensure examination.12,13,15,16
Four studies12,13,15,16 used passing the NCLEX-RN as an outcome and correlated nursing course repetition with a greater chance of failing the NCLEX-RN. Domiano15 found that even repeating a prerequisite course was correlated with NCLEX-RN failure. Abele et al14 demonstrated the association between repeating and program attrition, using graduation from the nursing program as the outcome of interest. They found that nursing course failure and repetition were correlated with a decreased likelihood of completing the nursing program, especially if the student failed and repeated more than 1 course.
Boughan9 studied the progression of nursing student repeaters and found that it was common for them to pass the repeated course but then go on to fail a subsequent course. Harding et al11 had the same finding, which they further analyzed by timing of the initial course failure. They found that students who failed and repeated the last semester of the nursing program were successful but that all of the students who failed in an earlier semester of the program eventually failed again.
One study contributed a perspective on the economic cost of course repetition for nursing students. Schulmerich and Hurley16 calculated the cost of both remediation and course repetition along with lost income opportunity as $1.6 million for the students in their study. The costs were calculated based on tuition expense for remedial and repeated courses and the estimated income lost by delaying graduation and entry into the workforce as an RN. Additional costs that could have been incurred by the students or institution, such as tutors and other academic resources, were not included in this calculation.
Despite the evidence of negative outcomes for nursing student repeaters, the literature suggests that, with the proper support, they can be successful. Two articles described intervention studies, both implementing tutoring programs for nursing student repeaters. Bryer10 described a program in which peer tutors provided academic and emotional support, resulting in academic success for 8 of 11 program participants. Guerra-Martin et al18 conducted an experimental study in which the experimental group (22 students) received academic and emotional support from professors in their tutoring program; more of the students who received the intervention passed the course that they were repeating in comparison to the control group (also 22 students).
The quantitative studies did not provide an explanation for the causes of nursing student failure. The life circumstances or other contextual factors that may have contributed to nursing students failing and needing to repeat a course were better described in the qualitative studies.
Five qualitative studies were analyzed for this review, 4 of which were based on dissertation research.1,20-22 Gerow20 and Handwerker21 both used a phenomenological approach, Karsten and DiCicco-Bloom22 used grounded theory, and Lewis1 used narrative inquiry. The fifth qualitative article was by Crow and Bailey23 and was based on data collected from a larger, ongoing qualitative study that was not described; no specific qualitative methodology was identified.
The qualitative studies all sought to describe the personal experiences of nursing student repeaters, and all studied the population of ADN students. As is typical in qualitative research, the number of participants in each study was small, ranging from 5 students23 to 16 students.22 There was alignment in the findings from these studies, with similar concepts identified: (1) Nursing student repeaters experience painful consequences that are social, financial, and emotional, in addition to the academic consequences of failing and repeating.1,20,23 (2) Students have complex lives and multiple responsibilities in addition to school.1,22 (3) They are surprised at the academic rigor of ADN programs and often underestimate or are unprepared for the challenge.1,21,22 (4) Acknowledging failure is a challenging process that involves grief and loss.1,21,22 (5) Nursing students who repeat courses need help and support from family, faculty, and other students, including other repeaters.1,20,22 (6) Part of understanding the experience of failing and repeating involves seeing value in the experience or even choosing to view it in a positive way.1,20
The qualitative researchers provided many similar recommendations. The importance of faculty support for nursing student repeaters was emphasized by Crow and Bailey,23 Gerow,20 and Karsten and DiCicco-Bloom.22 The authors recommended that faculty use relational pedagogies and caring actions.14,15 Another recommendation was that programs provide clear and detailed progression policies and share them with students to permit course withdrawals when appropriate.21,23
Three articles that were not based on research were included in the review, 2 first-person editorial or essay articles24,25 and 1 article proposing mental health and spiritual support for nursing student repeaters.26 The editorial-type articles were similar in content, describing the emotional and psychological consequences of failing a nursing course and having to repeat. Cross24 framed her reactions as a grief experience, citing Kubler-Ross' death and dying theory, and further situated her experience in the context of struggling with a learning disability. Schoonover-Shoffner25 described her experience with failing and repeating as both an emotional and spiritual challenge, ultimately choosing to view the experience as a positive one in terms of spiritual and professional growth.
Wynn26 described the nursing student repeater experience from the perspective of a faculty member who is also a mental health practitioner. She identified mental health concerns, such as depression and anxiety, as both contributing factors and consequences of academic failure and course repetition in nursing school. Wynn further called for mental health nursing faculty to provide emotional and spiritual support for nursing student repeaters.
This scoping review reveals that nursing student repeaters have been a population of concern for the last several decades in prelicensure nursing education programs at both the associate degree and baccalaureate levels and in multiple geographic settings. The case is clearly made that nursing student academic failure and course repetition have consequences that impact the individual, institution, and profession. These consequences are academic, emotional, social, and financial. It is evident that nursing student repeaters are at increased risk of poor outcomes and may require additional support to be successful.
Nursing program policies and faculty behaviors influence the experience and outcomes of nursing student repeaters.23 Nursing programs may permit a student to repeat zero, 1, or more than 1 course. It is difficult to compare the outcomes of nursing student repeaters from one school to another when policies are varied. A more comprehensive description of nursing school policies and the incidence of nursing student repeaters would be a valuable addition to the literature.
Other perspectives on the topic of nursing student repeaters are not thoroughly addressed in the literature. One missing perspective is a clear explanation of the economic cost of nursing student failure and course repetition. Although Schulmerich and Hurley16 calculated a cost for the students in their study, it is important to capture the cost in other settings. In 1993, Boughan9 stated that it would be necessary to admit 167 students into his ADN program to graduate 100 nurses 2 years later. Even without considering the personal costs of repetition and attrition, it seems probable that there is a financial case for institutions to support nursing student repeaters rather than attempt to replace them in their programs. Further studies to describe the financial impact of repeating in varied settings and circumstances are important to help institutions determine the most economical interventions.
The other significant gap in the literature is in the area of interventions to support nursing student repeaters. Two studies10,18 have demonstrated that tutoring programs can be beneficial for these students, but their studies considered outcomes of the course being repeated, not any longer-term outcomes. It remains to be demonstrated whether such programs result in the success of these students in subsequent course work as well as the impact on program completion and passing the licensure examination. When considering the qualitative literature, it is evident that many factors contribute to nursing student failure and course repetition; tutoring programs are an excellent start, but interventions are also needed for the financial, emotional, social, and other consequences experienced by nursing student repeaters. It would be valuable for researchers to study interventions to support these students academically, emotionally, socially, and financially.
Strengths and Limitations of Review
Strengths of this review include the consideration of citations dating back to 1972, from any country, and from the gray literature. This process allowed for recognition of the topic's importance, even though the literature is limited. This scoping review included quantitative and qualitative studies from a variety of methodologies.
There were also several limitations to the review. The most significant limitation, which is true of scoping reviews in general, is that the quality of the studies was not evaluated. Because of this limitation, it is not possible for this scoping review to provide a basis for policy or practice recommendations, although it is possible to identify the most obvious gaps in the literature. Other limitations include the inclusion of a limited number of databases and the review of only abstracts and articles that were available in English.
Nursing student repeaters have the potential to contribute to the nursing profession but may require additional support to be successful. As a population of students, they are not separated in the publicly reported data of nursing schools and have thus been underrecognized. Nursing education researchers have been interested in nursing student repeaters for many years, and both qualitative and quantitative studies have been done. Other authors have written from a first-person perspective about the experience of repeating a nursing course or about their attempts to help nursing student repeaters.
Needing to repeat a nursing course is correlated with numerous negative outcomes, including subsequent course failure, attrition from the nursing program, and failure to pass the NCLEX-RN. There is a significant economic impact on nursing students when they need to pay additional tuition for remedial or repeated courses and experience delay in earning wages as an RN. The consequences of failure and repeating a nursing course are also emotional and social for nursing students. Students experience grief and loss and have to seek new perspectives and support from others to move forward.
The literature provides a start to understanding this population and exploring ways to support them; however, there is limited evidence. Additional research is needed to better explain the circumstances and impact of nursing student repeaters and to identify and study interventions to support them.
Thank you to Jamie Conklin and Amanda Woodward for library assistance.
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