Physical and mental determinants of dropout and retention among nursing students: protocol of the SPRiNG cohort study

In an aging population, a shortage of nurses poses a serious threat to the continuity and quality of health care. This shortage often results from increased demand combined with a declining number of new workforce entrants [1]. In the Netherlands, the number of registered nurses has decreased since 2013 [2] and there is a shortage of specialized nurses (i.e. emergency and intensive care, oncology, neonatology nurses) [3]. Moreover, the demand for nurse practitioners in the Netherlands is expected to double by 2028 [4].

The shortage of nursing professionals is also a growing concern in the European Union [5]. The European Commission Health workforce acknowledges that there is a significant employee turnover in some fields of health care due to the demanding working conditions [6]. Dropout of nursing students and the early exit of nurses starting their career contribute to this shortage. Research in Australia [7], the USA [8], Canada [9], the UK [10, 11], Finland [12], Ghana [13], Japan [14] and Sweden [15] has shown that, among nurses, physical and mental health problems can lead to dropout and early exit, and that this is a global problem.

The numbers of dropout differ between countries. For example, in the UK in 2015 the average dropout rate for student nurses at universities was ≥20% [16]. In Italy in 2011 the nursing students’ academic failure rates were 35–37% [17]. In the Netherlands, the dropout rate among nursing students increased slightly between 2005 and 2013 from 20.5% to 21.1%, respectively [18].

Dropout is a complex issue involving a wide range of factors. In Europe, two studies investigated the early exit of nurses and both reported that a considerable proportion of nurses considered giving up nursing [19, 20]. In 2003, the multinational NEXT study [19] showed that the proportion of participants considering leaving nursing (several times per month, or more often) ranged from 8.8–36.2% in the participating countries [19, 21]. In the RN4CAST study (a cross-sectional study including 12 European countries), the percentage of nurses that intended to leave their current job ranged from 19 to 49% [20]. In the LANE study, the career pathways in three cohorts of Swedish nursing students were prospectively followed for the first three years of their working life [22]. The intention to leave the profession one year after graduating ranged from 10 to 20% and was more common among younger nurses; in the 2002 cohort, about 2% of the participants had actually left the nursing profession within five years after graduation [22]. This indicates that the intention to leave does not necessarily lead to actual turnover.

The intention to leave nursing education or the nursing profession is associated with determinants of study burnout [23], job satisfaction, organizational commitment [24], job demands and work engagement [25]. In 2003 the determinants of stress, burnout and attrition in nursing students, and the relationships between these determinants, were measured in a prospective longitudinal cohort study; the results show that stress, burnout and attrition might be indirectly associated [26].

In the Netherlands, research among 11,000 healthcare employees (including 3057 nurses) revealed that many suffered from physical or mental health complaints due to work-related issues [27]. Nurses reported problems related to the locomotor system, severe fatigue, and feelings of frustration or burnout. In the latter study, half of the nurses reported to have visited a healthcare professional for physical problems, and one out of six for mental problems [27].

It is unclear to what extent (student) nurses already perceive these health problems during their nursing education and/or at the beginning of their career, and to what extent these health problems cause students to dropout from nursing education or their profession. Therefore, the SPRiNG (Studying Professional Resilience in Nursing students and Graduates) project was started. SPRiNG is a collaboration between Rotterdam University of Applied Sciences (RUAS), Erasmus University Medical Center, Amsterdam University Medical Center, and the Netherlands Institute for Health Services Research (NIVEL).

This article describes the protocol of the SPRiNG cohort study. The aim of this prospective study is to examine dropout and retention of nursing students during their education and/or at the start of their career, and the related protective and risk factors.

This study will provide information on 1) the prevalence and the incidence rates of dropout, 2) the protective and risk factors, and early indicators of dropout, and 3) the interactions between these factors and indicators. This article describes the protocol and methodology of the study.