Introduction

This quality improvement study aimed to prepare our nursing students better to handle the rigors of the AAS nursing program, prepare for nursing licensure and gain swift entry into the workforce. Student attrition in this public university ranged from 30% to 50% in the first semester of nursing for several years. The nursing students represented much academic, generational, cultural, and linguistic diversity. Non-traditional students may also have been challenged to balance multiple roles and are unfamiliar with the strategies, skills, and time commitment needed for nursing student success. Using a holistic approach, success coaches worked closely with students; however, both the student and success coach should have been active participants for the success coaching to be effective and achieve optimal academic outcomes.

Before implementing the student success coaching program, faculty met with students in the last few weeks of their last semester nursing course in the AAS (associate in applied science) program (right before the student could take the NCLEX-RN). It was too late to help students at high risk of not passing NCLEXRN (National Council Licensure Exam-Registered Nurse) based on ATI (Assessment Technology Institute) standardized predictor exams. Proactive measures were not possible or practical at this stage of the program. Many students have already dropped out or have withdrawn from the nursing program. NCLEX-RN first-time pass rates declined 63.6% in 2014.

Proactive interventions to optimize student success should begin before and during the first semester of nursing. Reducing attrition rates, increasing program completion, and increasing NCLEX-RN pass rates have been significant concerns for nursing programs. It drives nursing schools to develop ways to increase student success and pass accreditation standards [2,4].

Nurse educators need to develop and implement programs to support nursing students. There needs to be a reflection on current retention strategies [5]. Student retention is multidimensional and intricate. Several studies support that non-traditional students attempt to balance many roles, such as student, caregiver, breadwinner, and or parent [4,6-8]. Students may be unaware of the challenges of undergraduate nursing education. Benner, Sutphen, Leonard, and Day (2010) called for a transformation of nursing education for both the student and the educator. Academic coaching was one of the recommendations. Coaching and mentoring have been used in the clinical arena for new nurses and new nurse leaders. Communication and feedback are keys to better outcomes [9].

Minority students may face many challenges, such as financial issues, inadequate academic preparation, and deficient study skills. These factors may be barriers to the successful completion of an undergraduate nursing program [1,4,7,10]. Furthermore, withdrawing from a nursing program is further amplified when students lack support programs [7,11,12]. The first semester of nursing is critical since the decision to withdraw from a nursing program often occurs within the first six weeks of the first semester [13,14]. Identifying students at risk of dropping out of nursing programs is paramount. A literature synthesis supports identifying students at risk for failing or withdrawing from nursing programs early in their careers [2,4].

The literature indicates that all students can benefit from proactive and ongoing nursing support strategies, especially before and during the first semester [8]. Therefore, coaching can influence academic success in higher education. Support systems must be implemented and evaluated to optimize student outcomes [16].

The theory of Integrative Nurse Coaching uses a holistic approach to support positive outcomes and support behaviour [17]. Nurse success coaching is “purposeful, skilled, and goal-oriented” (American Nurse Association, 2015) [18]. The American Nurses Association recognizes the power of success coaching (American Nurses Association, 2015). Nursing faculty must identify variables that affect attrition, especially in non-traditional students at higher risk for non-completion.

The literature reports increased satisfaction, resilience, retention rate, and course and program completion [19-21]. Student retention and success remain a priority for nursing programs. Nursing faculty must identify variables that affect attrition, especially in non-traditional students at higher risk for non- completion. Resources for student success need to be funnelled into those areas where it is most needed [22]. Students who are identified as at-risk are underrepresented students, those with an English language barrier (English as a second language), those who are economically or educationally disadvantaged, and students with family responsibilities. Faculty have shared responsibility for student retention with other departments. Providing support academically and with non-academic factors can enhance student retention and facilitate academic success [23].

Reasons for attrition have been noted as a perceived lack of support from faculty, qualityteaching, and feeling unprepared for nursing practice [12]. Faculty members are the primary contact for students and have the potential to impact student experiences. Faculty should promote positive relationships with students and take a holistic approach to student interactions. Nursing faculty can identify and intervene with academic problems and nonacademic problems. Students need to be directed to resources immediately [15]. Professional integration and socialization can influence retention during the first semester of nursing [22].

There are challenges to nursing student retention. Academic advisement strategies need to be implemented, as well as retention programs [23,24]. Student retention is multidimensional and requires multi-faceted interventions. Resources such as student and faculty time and money are wasted when students fail. Because of the need to improve student success, nursing programs have focused on the benefits of success coaching. These include time management, study skills, stress management, active learning strategies, tutoring, professional socialization, and advisement [15,22,25]. Nursing faculty must identify variables that affect attrition, especially in nontraditional students at higher risk for non-completion [4,7,26].

Jeffreys NURS model (2012) [13] is a framework used to appraise the multidimensional variables that impact undergraduate nursing student retention and success. It looks at why students stay in undergraduate nursing programs. The main aim of the model is to retain undergraduate nursing students. Assumptions include the prioritization of undergraduate nursing student retention. It is intricate and involves many dimensions; environmental factors and professional integration impact retention, all students can benefit from enrichment and professional socialization, and psychological and academic outcomes influence persistence. Professional integration factors are central because they influence students to persist or drop out.

The nursing student success coaching process is based upon the ANA’s professional nurse coach practice and performance competencies. It is also based upon principles of nurse coaching from the International Council of Nurses and the Honor Society of Nursing, Sigma Theta Tau International. The seven-step Process is a user-friendly guide for student success coaching sessions. Each step is briefly introduced. The Nurse Coaching Process is a revamp of the nursing process. It includes the following steps: establishing a relationship and assessing readiness for change, identifying opportunities and concerns, establishing outcomes, planning, empowering clients to reach goals, and determining if goals were met or not. The Nurse Coach competencies are associated with ANA standards of practice, the professional standards of professional performance, and evidence-based practice and research [18].

Materials and Methods

Formal Preparatory Strategy

Success coaches were select nursing faculty who integrate ANA (American Nurses Association) coaching competencies, evidence-based theory, and best practices on student retention to optimize nursing student outcomes and success. Success coaches have completed the continuing nursing education module of “Coaching in Nursing” by Sigma Theta Tau International Honor Society of Nursing and the International Council of Nurses [27]. In addition, select faculty have attended a faculty development workshop on success coaching. Faculty could have mock success coaching sessions while playing the roles of faculty success coach and first-semester student.

STEP 1-Group Success Coaching during the Nursing 110 (Medical-Surgical Nursing I) Student Orientation

Although the concept of success coaching is advertised and disseminated to aspiring nursing student applicants via the nursing website, bulletin board postings, letters, announcements, and other venues, the seven-step success coaching process formally begins with group success coaching during the new pre-semester nursing orientation. Students are notified electronically to save the orientation date and submit their weekly time management schedule. Nursing didactic course instructors conduct the orientation prior to the start of the semester. They are joined by critical faculty and staff such as the dean of health sciences, the department chairperson, success coaches, peer mentor tutors, nursing student club officers, the chief college lab technician, the nursing neighborhood coordinator, and academic support counselors. Due to the Covid-19 pandemic, sessions were conducted on the Zoom platform.

Using a variety of informational and interactive components, the orientation topics include welcome and introductions, enhancing your textbook reading comprehension, enhancing your learning skills in the classroom, making the most of your notes, time management, family, faculty, and friend support networks, optimizing academic success through the Nursing Neighborhood resources and services (Nursing Student Resource Center); Nursing Student Test Prep Center; test-taking computerized programs and more), Stress: Preventing, managing, and coping: Individual strategies and college resources. A member of the counseling department participates in the orientation.

The Nursing Student Retention and Success Coach Coordinator briefly introduces and discusses success coaching. Students are then instructed to complete the prelicensure demographic data sheets (adapted from Jeffreys, 2012b). The purpose of the prelicensure demographic data sheet is to provide student profile characteristics. It also identifies non-academic and academic factors that the higher education and nursing literature may influence student retention and success, especially in the first semester (i.e., credit load, educational background, primary language, employment responsibilities, finances, ethnicity, and childcare).

A copy of the prelicensure demographic data sheet will be available for success coaches to prepare for their initial session with their assigned students. Next, the first-semester didactic course instructors review and discuss the Success Coaching Agreement. The purpose of the Student Success Coaching Agreement is to specify the terms of the student and success coach relationship. The student must bring this to the initial 1:1 face-to-face coaching session. The students must complete the weekly time management schedule before meeting with their assigned success coach.

The Nursing Student Retention and Success Coaching Coordinator introduces some faculty success coaches and peer mentor tutors at orientation. The incoming nursing students are then divided into groups led by a success coach. The purpose of the grouping is to allow formal socialization of students. Each student belongs to a clinical and college lab section based on registration. Socialization strategies focus on the socialization of the role of nursing students among fellow peers [11]. The success coaches present at the orientation are provided with an outline that addresses common difficulties that students face in their first semester of nursing. The scenarios include being unable to keep up with readings and written assignments, the importance of lab practices, juggling family/work commitments, anxiety, and overconfidence. With the guidance of the faculty success coach, the group collectively develops and evaluates a strategic plan.

Student nurse representatives and success coaches will take students on a tour of the Nursing Resource Room, Nursing Test Prep Center, the college lab, and the classrooms where the nursing didactic component is held. Past success coaching events were highlighted. The orientation is then concluded.

Step 2 -Establish A Relationship Via 1:1 Face-T0-Face Meeting/ Assessment

The student makes an appointment with their assigned success coach within the first two weeks of the semester. The first success coaching session should last approximately 20-40 minutes. The success coach reviews the prelicensure demographic data sheet and the nursing student success coaching agreement form. There is a discussion about the role of the student and the role of the success coach. Both parties sign the student success coaching agreement. The student and success coach will mutually establish goals within the scope of success coaching. The success coach reviewed and discussed the completed weekly time management schedule during the first face-to-face meeting. This may be revised as needed.

The success coach starts the Individual Coaching Session Form for each student. The student is assessed for coaching readiness. The success coach looks for verbal and non-verbal cues in the assessment. The purpose of the Individual Coaching Session Form is to assist the student in formulating a realistic and strategic action plan for academic success. Their success coach will give students a copy of this form.

Step 3- Diagnosis

The success coach clarifies any issues or concerns and identifies any opportunities for change if needed. It is not meant to label a student. Students may be unaware of the rigors of the nursing course (the amount of reading, studying, skills practice, critical thinking questions, and written assignments) and may not be ready or motivated for success coaching.

Step 4- Outcome Identification

The student and the success coach will collaborate to develop realistic and measurable short- and long-term goals (s) that are student-centered.

Success Coaching Events

Examples include the student completing weekly reading assignments and papers by the due date, or the student will progress to the following nursing course (short-term). The desire to become a nurse practitioner (longer-term goal).

Step 5- Planning

The student and the success coach mutually plan strategies to achieve goals. An action plan is developed. An example would be to reduce work hours or credit load. The student could also seek assistance from faculty, parents, other family members, peer mentors, or friends. The student may be referred to counselling if needed.

Step 6-Implementation

The student will implement the strategic plan. The success coach will empower and motivate the student to reach the goals set.

Step 7- Evaluation

The student and the success coach will follow up to evaluate the student’s progress via CSI e-mail, phone, Zoom, or faceto-face. The evaluation is based on the student’s perception of success toward goal achievement. If the student’s strategic action plan is unsuccessful, steps 2- 6 may need to be revised. Various success coaching events were conducted to promote professional integration into nursing. 

Study of the Intervention(s)

A pre-licensure demographic data form was administered and collected from the students at orientation. This allows faculty success coaches to become familiar with the students before their first meeting. On week 12 of the semester, the Student Success Coaching Program Survey was distributed and collected from students. Permission was obtained for the surveys since it was “Adapted from Enrichment Program Satisfaction Survey (EPSS) and Nursing Student Resource Center Survey (NSRCS), Items 6 and 7, in Jeffreys, M.R. (2012) [13], Nursing Student Retention Toolkit, New York, NY: Springer, with permission from Marianne R. Jeffreys and Springer Publishing. The demographic data form was used to identify students at risk. For example, students may work over 40 hours, attempt a 20-credit course load, or English may be their second language. Early identification of students’ strengths and weaknesses at the beginning of the semester is beneficial. Proactive interventions will assist students in preparing academically and optimize performance, satisfaction, and success [13].

The Pre-Licensure Demographic Form was administered and collected from students before the first day of classes. The Student Success Coaching Program Survey assesses general and specific satisfaction (success coaching). This survey was administered for anonymous completion on the 12^th week of class of each semester. Time was set aside in class to complete the survey. The Student Success Coaching Program Survey was adapted by the project leader from the Enrichment Program Satisfaction Survey (EPSS) and Nursing Student Resource Center Survey (NSRCS), Items 6 and 7, in Jeffreys, M.R. (2012) [13], Nursing Student Retention Toolkit, New York, NY: Springer, with permission from Marianne R. Jeffreys and Springer Publishing. The original Satisfaction Questionnaire (SQ) was an 8-item survey. It used a Likert-type rating scale: “strongly agree” to “strongly disagree.” The original SPS had an alpha coefficient of 0.87.

All students in the success coaching program met AAS preadmission eligibility requirements. They had a minimum GPA of 3.0 in the prerequisite courses (English 111; Philosophy 130; Psychology 100, and Biology 150), a minimum cumulative GPA of 2.5, and competitive scores on the NLN-Preadmission Registered Nurse Exam (NLN-PAX).

Demographics of participants

A review of the most recently available student demographic data academic year confirmed that our students continue to represent diversity in educational background, ethnicity, first language, financial need, educational background, and nonacademic responsibilities (Table 1 and Table 2). 

Table 1: AAS Student Demographics: Gender, Age, and Race/Ethnicity.

Table 2: AAS Student Educational Background and Nonacademic (Outside) Responsibilities^*.

Table 3: ADN Annual Program Completion Rates and NCLEX First-time Pass Rates^*.

Table 3 depicts a review of the annual program completion data. Data disaggregated by cohort noted improvement in on-time program completion from 39% to 53% (2016-2020), and the NCLEX First-Time Test-Takers Pass Rate improved from 64% to 93% (2014-2020). This data was not part of the original study.

Results

A formal Success Coaching program was initiated in the Spring of 2016 for students entering their first nursing course: MedicalSurgical Nursing I. Surveys regarding the Success Coaching program were distributed during an introductory nursing class after the 12th week between the Baseline (Fall 2015, pre-formal implementation) and the most recent semester available for analysis (Fall 2020). The sample size was 719 nursing students who participated from Fall 2015 to Fall 2020. There were 715 usable surveys.

The survey consists of 8 questions regarding satisfaction with nursing in general and with the components of the Success Coaching program specifically. Each question was rated on a 4 -4-point scale (Strongly Disagree, Disagree, Agree, Strongly Agree) and was analyzed individually using Chi-Square analyses. Data were condensed into Agree (combining Strongly Agree and Agree responses) and Disagree (combining Strongly Disagree and Disagree responses) to facilitate the presentation of findings. Analyses were also computed on the uncombine four-category data, and results were similar to the two-category results, which are presented below.

Table 4: This is the percentage agreement for satisfaction survey questions at Baseline (Fall 2015) and subsequent semesters, with a chi-square comparison to the Baseline rate of agreement (N = 719).

Figure 1: Proportion agreement for Question 3 (“Overall, I appreciate access to the Success Coaching Program services and resources”) and comparison to baseline agreement rate. ^*Statistically different (Chi-Square test, p < .05) from Fall 2015

Figure 2: Proportion agreement for Question 4 (“Overall, I am satisfied with the Success Coaching Program”) and comparison to baseline rate of agreement. ^*Statistically different (Chi-Square test, p < .05) from Fall 2015

Figure 3: Proportion agreement for Question 5 (“ My assigned success coach was helpful”) and comparison to baseline rate of agreement. ^*Statistically different (Chi-Square test, p < .05) from Fall2015

Figure 4: Proportion of agreement to Question 7 (“The Success coaching workshop was informative”) over time and comparison to baseline Fall 2015) rate of agreement. ^*Statistically different (Chi-Square test, p < .05) from Fall 2015

Chi-square analyses were computed to compare the rate of agreement and disagreement at each semester to the Baseline Semester of Fall 2015. All questions showed semesters with improved agreement, although there were also semesters with no change and a few instances of significantly worsening agreement. Table 4 displays the results for Questions 1, 2, 5, 6, and 8, and Figures 1 through 4 show the results for Questions 3, 4, 5, and 7.

Question 1: “Overall, I am satisfied with nursing as my career.” Results (Table 4) show very high levels of satisfaction with nursing as a career overall, with 95% (n = 60) showing satisfaction at Baseline, leaving little room for improvement. However, statistically significant improvement was seen in the Spring and Fall of 2020, when satisfaction rose to 100%.

Question 2: “Overall, I am satisfied with the learning opportunities at the college.” At Baseline, 82% (n = 53) agreed with this question, and there were statistically significant improvements in 6 of the following ten semesters, with agreements between 96 and 100%. None of the semesters showed a decrease in agreement.