The lived experience of women studying nursing online in regional, rural and remote areas: an integrative literature review

There is a critical shortage of registered nurses working in regional, rural and remote (RRR) Australia, with only 28% of nurses choosing to practise in these areas [1]. Nursing students living in RRR areas are the most likely people to address this shortage [2, 3]. The problem is, however, higher education students from RRR areas are an identified equity group who experience poorer educational outcomes in comparison to their metropolitan counterparts. For example, even if they were to consider nursing as a career, RRR students are 40% less likely than students from metropolitan areas to gain a tertiary level qualification at all, and 50% less likely to gain a Bachelor degree by the age of 35 [3]. Despite such challenges, supporting students to remain in RRR areas while they study reduces the need for students to relocate to metropolitan areas and subsequently promotes the opportunity to continue to live and work in RRR areas during and after graduation, reducing the nursing shortage.

The Regional, Rural and Remote Tertiary Education Strategy [3] called for action to improve educational opportunities and outcomes for RRR Australians. This integrative literature review aims to identify:

“what is known about the experiences of regional, rural and remote Australian women undertaking a Bachelor of Nursing program delivered online?”.

Ultimately, the result of the literature review is to determine the direction for future research that in turn could better understand the experiences of and subsequently improve the retention and completion rates of women studying nursing in regional, rural and remote (RRR) Australia, and ultimately redress the workforce shortage of one of Australia’s vulnerable populations.

The methodology is an integrative literature review adapted from the processes outlined by Whittemore and Knafl [4] which included: 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis and 5) conclusion. Articles identified as part of the review explored different aspects of the research question. Together, the articles help to draw an understanding of what is known about this topic, and where there is clearly opportunity for further research and understanding.

Abstracts were reviewed against the inclusion criteria (Table 1). Excluded articles were held in an individual file and reviewed by the research team to identify whether any had been excluded in error. Three articles were subsequently determined as meeting the inclusion criteria. Due to the diverse representation of the literature, and that it was also agreed no one article answered the research question, using the process of Whittemore and Knafl [4], each selected article was coded according to two key criteria: methodological rigour and relevance to the research question. When coding, a score of one or two was applied, with one indicating the highest methodological rigour and relevance to the research question. A score of two did not exclude the article, however it meant that the article was assigned a lesser weight during the analysis stage. After the researcher applied the coding, the team undertook a blind coding of the articles, confirming the scoring, adding another layer of rigour to the analysis.

A table was constructed outlining each article’s author, title, country of origin, purpose, methodology, participants, key findings, limitations and score out of two [4, 11, 12] (Table 3). The table facilitated the systematic comparison of the articles and served as the starting point for interpretation.

Using a qualitative analytical method, the articles were first presented in a review matrix (Table 3) as suggested by Braun and Clarke [22] and subsequently ordered and categorised according to their primary focus [4]. Inductive “complete coding” identified new themes that were relevant to the research question, p. 206 [23]). These codes were then collated into early themes. Four interrelating themes were identified: (1) juggling “women’s work” and study, (2) the online learning environment is isolating, (3) the cost of clinical placement, and (4) maintaining overall wellness while studying. Importantly, no one theme stands alone but shows the intersection of complex challenges facing this group of students.

It is known that there is great disparity across tertiary education participation and attainment rates between RRR and metropolitan individuals [3]. The Regional Education Expert Advisory Group [3] reported that curriculum is designed for the lives of metropolitan students, impacting RRR student success. Bachelor of Nursing student characteristics include non-traditional enrolment categories of mature-aged, female, first in family, RRR geography, and low-socioeconomic status. This information supports that intersectional issues occur for RRR students enrolled in Bachelor of Nursing degrees specifically, resulting in unique challenges that inhibit success.

In this literature review, juggling “women’s work” with study inhibited study success as the complex responsibilities held by women were not understood or acknowledged by their partners or universities. This is significant because approximately 90% of BN students are female, and over half of these are mature aged (defined as older than 20 when enrolling [24]. Juggling “women’s work” and study impacts on learners’ success [25]. As acknowledged by Therborn [26], gender inequality is a complex and intersectional issue. The themes are in keeping with other research demonstrating that women are disadvantaged by social expectations and roles that include childcare, family responsibilities and domestic work which result in inequities in accessing higher education [27] and that the system of education itself, as well as the way in which society is structured traditionally, culturally and politically, can be significant barriers to a woman’s success in education [28]. In most western countries domestic duties continue along traditional gendered expectations and mature age women are more likely to have responsibilities associated with caring roles for children or older parents. Inflexible university learning and teaching expectations limit student success with regard to these responsibilities [26].

This literature review highlighted the intersecting challenges students experience when studying online. Regional, rural and remote learners explained that studying online was not necessarily their preferred learning style, but the only way they could access the degree.

One solution that has been proposed to rapidly address the nursing workforce shortage is to increase online offerings of the Bachelor of Nursing [29]. While an online enrolment option means increased opportunity to study for those living in RRR areas, those studying online experience higher attrition and lower completion rates than those students who study on campus [24, 30‐33]. As this literature review has shown, this is related often to a poor learning experience and lack of technological support. Lakhal and Klechine [34] who explored mature aged students from a broad range of disciplines concur with the results of the literature review. Their results led them to posit that gender, age and prior online course experience are variables which need to be understood when analysing the online learning experience. Further challenges for online learners in RRR areas include social dislocation, access to pastoral support and guidance, and establishing a sense of belonging within the online space [35]. Given the non-traditional age and gender characteristics of RRR, BN online learners, there may be further learning and opportunity for success that can be explored through a better understanding of these intersecting challenges.

Clinical placement was identified as a key challenge to success across all studies in this literature review. In Australia, to qualify and register as a nurse an individual must successfully complete an Australian Nursing and Midwifery Accreditation Council (ANMAC) accredited program. In all BN programs, including where students enrol in an online mode, there is a minimum number of hours students must spend face to face, engaging in simulation-based learning activities and clinical placement [5]. Bachelor of Nursing students need to complete at least 800 h of unpaid clinical placement throughout their degree [5]. Many students work part time hours to accommodate for the need to care for children or older family members [3], however BN students also need to complete their clinical placement on a fulltime basis with little flexibility offered [36]. As this review has shown, online nursing students need to travel long distances under difficult circumstances to reach campus and clinical placements. The Regional Education Expert Advisory Group [3] have demonstrated that this contributes to student attrition. Jafarian-Amiri et al. [37] too has noted the impact of compulsory clinical placements allocated at short notice and/or in locations far from home. The need to arrange childcare and leave from paid work can pose significant challenges for students, with intersecting challenges experienced by students in RRR areas where there is likely to be difficulty accessing childcare and accessing flexible working arrangements shown in this literature review and in the work of Stone and Davis (2020). The need to apply for leave from work at short notice is negatively perceived by workplaces and some students are not able to maintain regular paid employment throughout the degree, ultimately resulting in the need to prioritise paid work over pursuing study [36]. Over 30% of RRR students are reported to be from low socioeconomic backgrounds [3]. Students from RRR areas generally face increased financial pressures through their socioeconomic disadvantage and this result in early termination of their studies. In fact, over 30% of students from RRR locations cite financial pressure as the reason for leaving university, in comparison to 21% of metropolitan students [3, 38]. University policy and systems for clinical placement allocation are generally not supportive of individual student circumstances [36]. The studies in this literature review certainly suggest they are not. This lack of support substantially negatively affects the student experience. Looking more closely at how women experience the face to face requirements of the BN, such as clinical placement, while living in RRR areas will provide an evidence base for supportive ways in which these students can be retained within and successfully complete their studies.

In addition to financial pressure, students in the studies in this literature review also reported that health and stress were their greatest concerns impacting study success. This concurs with data from Quality Indicators for Learning and Teaching [QILT] [38]. Specifically, over 50% of RRR students cited stress as the most common reasons for departing their degree, compared with 44% of metropolitan students. There are significant challenges BN students face when looking to maintain a healthy work-study-life balance. The need to attend face to face learning on campus and at clinical placement reduces the time that can be spent being involved in regular sporting and community activities. Research by Luders et al., [36] agrees. Not knowing when or where a clinical placement will be allocated is obstructive to a regular study pattern and students constantly feel the need to adapt. A loss of sense of control is a common feature as students are told when and where they must go, without a period of consultation or consideration of life outside of study [36]. While these challenges are identified for BN students generally, the impact of these challenges when compounded with rurality, gender and online learning has not yet been explored.

No studies have been found that collectively explore the lived experiences of women studying a Bachelor of Nursing in the online mode in RRR Australia. The studies included in this review provide some limited insight into women or BN students or online learning or RRR student perspectives individually, meaning this paper provides evidence that currently available literature consistently fails to explore the intersection of the complex challenges facing these students. Using thematic analysis, this study was able to extrapolate four themes: (1) juggling “women’s work” and study, (2) the online learning environment is isolating, (3) the cost of clinical placement, and (4) maintaining overall wellness while studying. What is important about this integrative literature review, is that the themes identified provide a small and incomplete insight into the experiences of such women, and with a workforce shortage already in play and students continuing to withdraw from their studies, there is a need to find a way to better serve regional, rural and remote Bachelor of Nursing students and their communities.