Factors Associated With Dropout , Retention and Graduation of Nursing Students in Selected Universities in South Africa : A Narrative Review

Much has been discussed in workshops, meetings, seminars and nursing summits in South Africa but very little has been revealed in literature on the scourge of drop out, retention and graduation rates of nursing students. The authors reviewed literature related to dropout, retention, completion and graduation rates of nursing students in selected universities in South Africa. Journal articles from 2007-2016 were reviewed for emerging themes about nursing students’ dropout, retention, completion, success and graduation. Exclusion criteria: online or distance education programmes, postgraduate programmes, experimental or randomized control trials and previous review studies. Comprehensive electronic search was conducted for published longitudinal and crosssectional studies. Specific databases: PubMed, MEDLINE, EBSCO host, CINHAL. Specific search terms: [“student” OR “nursing”], OR [“dropout” OR, “retention”], OR [“graduation”, OR “education” OR “success” OR “completion”] AND “universities” OR “undergraduate” AND [“strategies” OR “interventions”]. Thirtyfour (34) studies met review criteria. Fifteen (15) (47.06%) of the studies reported results on attrition, 16 (47.06%) reported on retention and 3 (8.82%) reported on completion and graduation. Academic, personal, preparedness and social factors were associated with dropout, retention and graduation of nursing students in South Africa. Dropout from undergraduate nursing programme is fraught with many problems. There is a need for retention models. Without nurses, much of the public health outcomes will be hardly achieved. If the problem of dropout and retention with decreased graduation persists, the health services will be crumbled thus affecting the realization of the health outcome “a long and healthy lifestyle for all”.


Introduction
Whilst South Africa grapples with the quadruple burden of diseases on the health care system, there is a need for Nursing Education Institutions (NEIs) to pull up all the stops in producing quality, caring and safe nursing practitioners.However, there are serious concerns that need to be addressed by the NEIs, amongst which is a problem of dropout and retention strategies of nursing students in the undergraduate programmes.Figure 1 displays the production of nurses by the statutory body, the South African Nursing Council (SANC Statistics 2009-2011).(Fowler & Norrie, 2009;Jeffreys, 2007a;Letseka & Maile, 2008;Levett-Jones, Lathlean, Higgins, & McMillan, 2009).

Involuntary (Academic Factors)
Involuntary academic factors associated with dropout are academic difficulty coupled with lack of or inadequate support, under-preparedness, lack of commitment to the learning process, inappropriate study skills and habits, inadequate academic services, frequent absenteeism from class or clinical settings, lack of effective academic incorporation, financial constraints and language barrier (Andrew et al., 2008;Jeffreys, 2007b;Letseka & Maile, 2008;Pryjmachuk, Easton & Littlewood, 2008).On the other hand clinical placement with minimal support emerged as a factor in students leaving before graduation (Anonson, Desjarlais, Whiteman & Bird, 2008).

Student Affective factors
Students' affective factors consist of the attitudes, values, and beliefs about education, nursing, and one`s ability to succeed.This includes cultural values and beliefs, self-efficacy, and motivation.Attitudes, values and beliefs of nursing students can be modified when they are mentored by experienced role-models who understand and have insight into the various techniques in student accompaniment especially into the clinical setting.Educators can also influence student' self-efficacy and motivation during their educational encounter (Jeffreys, 2012).

Involuntary (First Semester Academic Dropout)
The first year experience has shown the need for urgent interventions targeted at first year undergraduate nursing students on admission if dropout rate is to be reduced and increased retention and graduation rates achieved.Factors associated with involuntary first semester academic dropout were perceived lack of support; financial constraints; environmental factors and difficult transition and integration into the tertiary environment (Jeffreys, 2007b;Jeffreys, 2012;Letseka & Maile, 2008;Tinto, 1993).

Retention Studies (n=16)
Sixteen ( 16) 40.07% of the studies found that mentorship programme tended to be facilitators of success for undergraduate nursing students.Researchers are of the opinion that a well-planned and well managed mentorship programme can reduce dropout and enhance retention, success and graduation of undergraduate nursing students.Besides mentorship programmes other factors pivotal between dropout and retention were support, academic preparedness and social (Baker, 2010;Nkutu & Seekoe, 2013).

Completion and Graduation Studies (n=3)
Three (3) 8.8% of the studies reviewed reported students with higher entry qualifications and above 80% class and clinical attendance obtained better marks or were more likely to succeed in nursing programmes.Conversely, students with lower entry qualifications and who frequently absented themselves from class or clinical settings were more likely to have lower marks or drop out of the programme (Veal, Bull & Miller, 2012;Williams, 2010).

Discussion
Literature revealed multidimensional factors related to dropout, retention and graduation of nursing students.Dropout trajectories were involuntary (academic), voluntary (personal reasons) and involuntary (first semester academic dropout).It is common to find first year nursing students quitting the undergraduate programme especially due to inadequate or lack of support and transition problems (Jeffreys, 2012).
Student profile characteristics have also emerged as factors in dropout, retention and graduation studies (Crombie et al., 2013;Eick et al., 2012;Fowler & Norrie, 2009;Hinsliff-Smith et al., 2012: Jeffreys, 2007b;Jeffreys, 2012;Sutherland, Hamilton & Goodman, 2007).However, maturity was seen as a predictor of success (Jeffreys, 2012).If a student has demonstrated good study habits and skills in prior educational programmes, and if they show up and get the necessary support, they would carry these skills to a new academic setting and attain their goals on time.The student affective factors also revealed that the belief patterns or system and values of students about education have an association with dropout, retention and graduation in undergraduate nursing programmes (Jeffreys, 2012).Future research should endeavour to examine the student affective factors and its association with dropout, retention and graduation in undergraduate nursing programmes, especially in the South African context.

Conclusion
The dropout, retention and graduation rates of undergraduate nursing programme in South African universities are fraught with a complexity of problems.There is a need for retention models.Retention-to-graduation models should be proposed to serve as recommendations.Without nurses, much of the public health outcomes will be hardly achieved (Savage & Kub, 2009).