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 [2] operating at various levels [4] determine why students leave. Staying is related to the extent of support that students receive, including family [10], 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 [11]. Nearly half of all students considered leaving their course in a large regional study of healthcare students in the United Kingdom [6] and this is similar to non-healthcare students, where up to 42% consider leaving [12]. Other aspects that are particularly challenging for healthcare students are the level of academic demands encountered [10, 13], the ‘reality shock’ of practice experiences [3] for those with no previous nursing background [14], feeling unvalued, unmet expectations and stress [15]. Leaving usually takes place in the first year of the programme [7] and being older is associated with staying [8]. Poor clinical placement experiences inform decisions to leave [3, 16] and mentoring is formative in the perception of placement experience [17].

The international evidence-base on student nurse recruitment and retention has developed since Glossop et al. [18] and Gaynor et al. [19] 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 [2], and reasons why they leave [1]. 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 [1]. 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 [2]. For Unwin et al. [4] 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. [3] 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 [12] 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.

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.

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 [2]: institutions that foster a sense of belonging generally retain their students more effectively than those that do not [12]. 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 [13]. 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 [32].

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 [3]. 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 [35]. High resilience has also been noted as essential in retention [11].

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 [36]. 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 [37] or religious [38] 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 [39], 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 [39], particularly as there is a strong expectation amongst the public that the values of compassion and care are still foremost for nurses [36]. The concept of vocation and the application of these values are seen as a counterbalance to impersonal, mechanistic care [40]; successful students attempt to match these ideals.

Moreover, having a low sense of vocation is associated with predicting attrition [41], 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 [42] 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.

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 [12], and nursing HEIs could fruitfully implement and evaluate these. In addition, Eick et al. [3] 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 [32] 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. [34] 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 [39], 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 [41] 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 [2]. 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 [12].

Study design GW, VH, TPC; data collection GL; data analysis GL & GW; manuscript preparation GW, VH & TPC Conflicts of Interest

The authors declare that they have no conflict of interest by any means with respect to this research manuscript.