Factors associated with nursing students' academic success or failure ...

Nurse Education Today 31 (2011) 59–64

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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

Factors associated with nursing students' academic success or failure: A retrospective Italian multicenter study A. Dante a, G. Valoppi b, L. Saiani c, A. Palese d,⁎ a

School of Nursing, Trieste University, Italy School of Nursing, Udine University, Italy Nursing Sciences, University of Verona, Italy d Nursing Sciences, University of Udine, Italy b c

a r t i c l e

i n f o

Article history: Accepted 17 March 2010 Keywords: Nursing student Bachelor's degree Bologna process Bologna Declaration Attrition Academic failure Academic success Factors Determinants

s u m m a r y With the increasing standardization of nursing education in Europe under the Bologna Process Declaration (1999), there is a growing interest in defining a common concept of academic success and/or failure, measuring associated factors and comparing differences and similarities between different countries. While there is literature available on these issues from other countries, the phenomenon has not been studied in Italy. The aim of this study was to define the factors associated with academic success or failure in an Italian cohort of nursing students on a bachelor's degree course. A retrospective multicenter study design was adopted. All students enrolling in the academic year 2004–05 on two different bachelor's courses in the north of Italy were interviewed. Only 81 of the 117 students considered (69.2%) concluded their course in three years. Multivariate analysis identified two factors determining academic success/failure: good results in the entry examination for the bachelor's degree in nursing sciences were associated with academic success (OR 4.217, IC95% 1.501–11.84), while family commitments, e.g. caring for children or elderly people were associated with academic failure (OR 0.120, IC95% 0.03–0.471). Academic failure has a strong impact on students, their families, the teaching faculties and the community, and its prevention is a challenge in the countries with a shortage of nurses. © 2010 Elsevier Ltd. All rights reserved.

Background Several national, regional and local strategies have been adopted to deal with the shortage of nurses in Italy (where the 370,641 nurses available are an estimated 60,000 too few (Silvestro, 2009)). Nationwide, thanks to the efforts of the National Board of Nurses, the Regional Authorities and the Ministry for Public Health, the planned number of places for students on bachelor's courses in nursing has risen from 12,000 to 14,944 in the last five years. By law, the number of students that can enroll each year for a bachelor's degree in nursing sciences (BNS) at the Faculties of Medicine is regulated according to the estimated number of nurses needed at national level. With the increase in the number of places available, the number of candidates has also started to grow. Where there used to be one candidate for each place, in the last academic year there were 2.4 candidates competing for each place (Mastrillo, 2008). It has become easier for the universities to recruit nursing students for several reasons, including the changing role of qualified nurses, their positive

⁎ Corresponding author. Nursing Science, Udine University, Viale Ungheria, 20, 33100 Udine, Italy. Tel.: +39 0432 590926. E-mail address: [email protected] (A. Palese). 0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.03.016

social image, and the occupational security of a job in the National Health Service. Once they have been recruited, however, retaining nursing students remains a challenge (Deary et al., 2003). Not all students finish their degrees course in three years, as required for the BNS by Italian standards under the Bologna Process rules. The Italian National Board of Nurses has estimated that only 7000 (63.1%) of the 11,100 nursing students who enrolled in the 2004–05 academic year on the BNS course actually graduated in the academic year 2006–07 (Federazione Nazionale Collegi IPASVI, 2004/2005, 2006/2007). Some students just took longer to complete the course, but 19–20% dropped out (Destrebecq et al., 2008). The academic failure rate has attracted a great deal of attention on the international scene (Andrew et al., 2008; Deary et al., 2003; Glossop, 2002; Salamonson, 2006), but less in Italy (Dante et al., 2009). It has become a priority to clarify the factors behind academic failures, be they related to intrinsic features of the students and/or to extrinsic characteristics of the BNS (its duration, learning workload, or format). A European database on the factors determining academic failures, comparing data from different countries and prompting those that have not yet reported on this issue might be of considerable benefit in the near future, given the effects that the Bologna Process (1999) (Miclea, 2003) is having on the organization of education in

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A. Dante et al. / Nurse Education Today 31 (2011) 59–64

Europe, in terms of standardizing nursing qualifications (bachelor's, master's and doctoral degrees) and regulating the credits, duration and format of each training cycle (Zabalegui et al., 2006). The aim of this study was to contribute to this debate by documenting the factors associated with academic success or failure in an Italian cohort of nursing students. Methods Study design and setting A multiphase study design was adopted. The first phase, described in this manuscript, as based on a retrospective multicenter study design. The second ongoing phase, currently underway, is based on a prospective multicenter study design. The preliminary retrospective study design was adopted due to: a) the lack of studies available in Italy documenting the factors relating to the academic failure; b) the urgent need to explore the academic failure rate and its determinants in order to develop short-term prevention policies; c) the need to document the main determinants affecting the academic success in order to include these as a variables in a prospective multicenter three-year study, following the students up from the admission to their graduation. Two universities in the north of Italy running the BNS course (Table 1) for approximately 250 students each, and with at least 80 students enrolled in the first year, were included. Participants All students who enrolled in the academic year 2004–05 for the BNS course were eligible, and students were enrolled providing: (a) they had not previously failed on a BNS course (at the same University or elsewhere); and (b) they had given their written informed consent to participation in this research. The study started in April 2008, when participants should have completed their BNS course. There were 146

eligible students, 13 (8.9%) of whom did not meet the inclusion criteria, and 16 (10.9%) refused their consent to the study. Data collection tools and procedures Given the lack of such studies in Italy, a preliminary review of the international literature was conducted, exploring all the issues associated with academic failure or success (Dante et al., 2009; Palese et al., 2009). A semi-structured interview consisting of 20 questions (18 closed and two open-ended) was prepared in the light of the factors identified in the literature. The variables included were: a) socio-demographic details (age, gender, nationality, place of residence, and family commitments, i.e. children and/or elderly adults to care for while studying for the BNS); b) background data (educational background; previous and concurrent work experience while studying for the BNS and, for working students, number of hours worked a week while studying for the BNS; other experiences, e.g. voluntary work); c) previous university experience in other fields, if any; d) main learning methods used by participants studying for the BNS (e.g. studying in groups, alone, taking notes during lessons) and perceived learning difficulties (e.g. yes/no); e) learning outcomes: number of exams failed on theoretical courses and number of tests failed at the annual practical clinical assessment; f) life events experienced while studying for the BNS (e.g. important changes such as disease or bereavements); and g) economic difficulties perceived while studying for the BNS (yes/no). Candidates were also asked whether they had ever thought of abandoning the course, and if they had any suggestions they would give other nursing students to help them achieve academic success. The semi-structured interviewed was first tested in a pilot phase including 10 students enrolling in the subsequent academic year (2005–06) and consequently not eligible for the study. The interviewers were given specific training (lasting 3 h) to contain interviewer variability in the conduction of the semi-

Table 1 Features of the BNS course in Italy. Affiliation

Faculty of Medicine

Denomination

Corso di Laurea in Infermieristica

Courses (n)

223 in all

Admission and enrolment

A nationwide entry exam testing general education, mathematics, logic and biochemistry is mandatory for all BNS candidates, as it is for other healthcare degrees. Candidates must have at least 12 years of prior formal education to apply. The exam is held in September. Candidates who gain a place can enroll on the course. Those who are rejected can sit the exam again in the following academic years and there is no limit on the number of attempts. University credits, hours, length 180 credits, at least 5400 h, 3 years Theoretical and practical clinical Bachelor's degrees according to the credit block system, dedicating approximately five months a year to theory and six months a year to training model practical clinical training, leaving one month for mandatory vacations. Lectures Approximately 30 credits a year, with 36 h of lectures a week. It is compulsory for students to attend at least 70% of the scheduled lectures. Clinical training Approximately 20 credits a year, 60 credits in all. It involves 1800 h (36 h a week). Attendance is mandatory. Clinical learning pathways start in general units (e.g., medical wards), then move to more complex units (e.g., intensive care) and community settings (mental health, community care, residential care). Number of theory examinations Approximately 6 each year Number of practical clinical One each year assessments BNS course organization 1) President (a full professor) 2) Coordinator (with a higher level university nursing qualification) 3) Lecturers (associate and full professors at the university and in-charge Professors from the National Health Service) 4) Nurse training managers for the clinical placements, with teaching experience and clinical expertise. 5) Clinical tutors or expert nurses on the wards, working with students during their clinical training. They are experts in the field of practice. 6) Student board: student representatives can take part in the collegial meetings of the BNS course staff. Tutorial resources Nurse training managers 1 for every 15–20 students. Tutors 1 for every 1–2 students. Final examination The BNS course ends with two exams, one to assess nursing abilities (awarding a professional license), while the other involves students discussing their thesis with an examining board consisting of Faculty staff and members of the Provincial Nursing Board.


structured interview. While the closed questions were recorded by the researchers during the interview, the open-ended questions were audio-recorded, giving participants the time and opportunity to express their feelings and opinions freely. Participants were interviewed in a private room at the university or at home, as they preferred. The interview took approximately 40 min. Each participant's results in the BNS entry examination were obtained from the records available on the University websites. Ethical considerations The study was approved by the Internal Review Boards of the Universities involved. An introductory letter was sent to all participants, before they were contacted personally by a member of the BNS teaching staff at each University, who gave them more details about the study, and all participants involved gave their written consent. The participants' anonymity and confidentiality were guaranteed throughout the study. Data analysis Participants were divided into two groups according to the aim of the study, i.e. (a) those who had been awarded the credits (180) needed for the BNS who had completed the course and graduated in three years, and (b) those who had not been awarded the required credits, or who dropped out during the three years. Depending on their scores at the BNS entry exam, participants were also divided into two groups according to how they were listed for the 80 places available at each University, i.e. students ranked from 1st to 40th, and students ranked from 41st onwards. The audio-taped answers to open-ended questions were transcribed verbatim by two researchers (AD and GV) and all transcripts were separately analyzed by three researchers (AD; AP; and GV) to ensure their thorough understanding and the identification of the most significant elements mentioned by participants. The researchers then compared these statements and divided them into several categories. The closed questions were processed using the SPSS Package (rel. 11.00), calculating the mean, median, mode, standard deviation (±), frequencies and percentages. Student's t-test and the chi-square test (or Fisher's exact test, as appropriate) were used to test differences between participants who graduated and those who failed, assuming statistical significance for differences with a p b 0.05. The risk of academic failure/success was expressed as the odds ratio (OR) and the 95% confidence interval (CI) was calculated using a regressive logistic model in a multivariate analysis.

Findings In all, 117 nursing students were interviewed, 35 (29.9%) males and 82 (70.1%) females. At the time of their interview, they were a mean 23 years of age (±5.20, range 18–43). Only 81/117 (69.2%) graduated in three years and there was no difference between the two universities (χ2 1.28, p = 0.25). Students who worked more than 16 h/week while they were studying had a higher probability of not graduating than those working less (OR 3.143, CI95% 1.319–7.488), and students with family commitments were also less likely to graduate than students without family commitments (OR 3.550, CI95% 1.361 to 9.258). The life of our students on the BNS course had not been easy: 51 (43.6%) reported experiencing life events and 38 (32.5%) said they had had economic difficulties; these students did not differ in their academic success or failure rates by comparison with those who had not experienced life events (χ2 1.78, p = 0.18) or economic difficulties (χ2 0.017, p = 0.89). Table 2 shows the characteristics of the participants.

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Learning strategies and outcomes The students reported using more than one learning strategy during the theory courses: 66 (56.4%) took notes during lessons, 26 (22.2%) tended to study alone, 14 (12%) preferred to study with classmates, 4 (3.4%) studied every day, 3 (2.6%) only attended the lectures, and 2 (1.7%) studied just before the scheduled exams. Only 2 (1.6%) students said they studied at the university library, spending a lot of time consulting books. The academic success rate among the students who reported having had no learning difficulties on the theory courses (77, 65.8%) was higher than for those who remembered having difficulties (40, 34.2%) (OR 2.682, CI95% 1.185 to 6.069). Of the 117 students, 99 (84.6%) failed at least one theory exam, 15/ 117 (12.8%) always passed, and 3/117 (2.6%) sat no exams because they abandoned the course before their exams were scheduled. The mean number of exams failed by the 99 students was 3 (±1.85, range 1–9). Failing one or more exams was not associated with failure to graduate (OR 1.74, IC95% 0.41 to 8.42). Of the 117 students, 26 (22.2%) failed the annual practical clinical assessment at least once, 81/117 (69.2%) never failed, and 10/117 (8.5%) did not take the assessment because they abandoned the BNS before it was due. The practical clinical assessment was repeated a mean 1.4 times (±0.69, range 1–3); the majority of these failures (16) occurred at the end of the first year, followed by 9 at the end of the second year and 3 at the end of the third. The students who always passed the practical clinical assessment (81) had a higher probability of graduating than those (26) who failed it once or more (OR 3.23, IC95% 1.12–9.39). Intention to abandon the BNS course Fifty-three students (45.3%) recalled that they had wanted to give up the course: 36 (67.9%) during the first year, 6 (11.3%) during the second and 10 (18.9%) during the third and final year. The main reasons for wanting to leave were: personal reasons (15, 28.3%), difficult relationships with the teaching staff (10, 18.9%), learning difficulties (8, 15%), the feeling they had chosen the wrong career (7, 13.2%), difficulties with the practical clinical training (5, 9.4%), disappointment with exam results (5, 9.4%), and the fear of being unable to complete the course (3, 5.6%). Those who remembered intending to leave had a higher probability of not graduating (OR 2.53, IC95% 1.05–6.15). Recommendations The majority of the participants interviewed (114, 97.4%) would recommend the BNS course, even those who failed to graduate. Their suggestions to improve future students' chances of graduating were, in order: to be strongly motivated to become a nurse (51, 44.7%), to be aware of the workload involved in the BNS course (26, 22.8%), and to study constantly (9, 7.9%). The other participants (28, 24.6%) recommended that students be well organized, take an active part in the lectures, have a vocation, study in groups with peers, take care over the first practical clinical assessment, and develop and maintain good relations with their tutors. Multivariate analysis Table 3 shows the multivariate analysis on the factors associated with academic success. Discussion Eighty-one of the 117 students who enrolled (69.2%) graduated from the BNS course in three years, which is more than the national average (63.2%) documented by the Federazione Nazionale Collegi IPASVI (2004/2005, 2006/2007). The international figures reported in the literature (Buchan and Seccombe, 2006; Hall, 2001; Hill, 2007) range

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Table 2 Characteristics of participants who did or did not graduate from the BNS course (by univariate analysis).

Age Mean Gender Female Male Nationality Italian Non-Italian Distance of faculty from home b30 min ≥30 min Where students live Within the region Outside the region Family commitments Previous education High school diploma Technical diploma Professional diploma Teaching diploma Diplomas awarded elsewherea Not known Final marks in secondary education (60 for a pass — 100 max) Mean Median Previous work experience As auxiliary nurses or nurses' aides Ranking in BNS entry exam 1st to 40th 41st or lower Working while on BNS course Average hours a week N16 h/week Voluntary work while on BNS course a

Graduated

Did not graduate

No. = 81 (%)

No. = 36 (%)

p-value

23.4 ± 5.50

22.1 ± 4.41

0.17

59 (72.8) 22 (27.2)

23 (63.9) 13 (36.1)

0.38

72 (88.9) 9 (11.1)

34 (94.4) 2 (5.6)

0.49

41 (50.6) 40 (49.4)

19 (52.8) 17 (47.2)

0.84

61 (75.3) 20 (24.7) 10 (12.3)

25 (69.4) 11 (30.6) 12 (33.3)

0.50

38 (46.9) 21 (25.9) 13 (16.0) 5 (6.2) 3 (3.7) 1 (1.2)

11 (30.5) 15 (41.7) 6 (16.7) 2 (5.5) 2 (5.5) 0

0.51

75.8 ± 12.11 74 48 (59.2) 12 (14.8)

68.8 ± 9.44 65.5 22 (61.1) 5 (13.8)

0.001

46 (56.8) 29 (35.8) 40 (49.3) 14.5 ± 9.3 15 (37.5) 23 (28.3)

11 (30.5) 19 (52.8) 19 (52.7) 22.2 ± 9.6 15 (78.9) 7 (19.4)

0.038

0.015

0.85 0.83

0.89 0.005 0.007 0.42

In countries with different secondary school systems.

from 63% to 94%, but caution is needed in drawing comparisons, partly because the degree courses differ in different countries, and also because our students were only interviewed after 3 years on the BNS course. Our findings should also be interpreted bearing in mind that some of the personal details reported concerning life events and perceived learning difficulties may have been influenced by recall bias. Moreover, a consistent number of students refused to participate, and these were probably the students who had the worst experience. Factors related to academic success or failure: univariate analysis The gender distribution (M:F = 1:3) and mean age (23 years) of our participants are consistent with the Italian nursing student population in the academic year considered (Federazione Nazionale

IPASVI, 2004/2005). Other countries seem to have a larger proportion of mature students: Kevern et al. (1999) found that at least 47% of students at a UK university were at least 26 years old, and similar data were reported by McCarey et al. (2007) from another university in the UK, where 33–50% of the students were 26 years old or more. Age does not appear to influence academic success rates, however, as documented in other studies (Pryjmachuk et al., 2009), while it may reflect the tendency to choose nursing as a second career. Gender is also unassociated with academic success rate, as reported by Kevern et al. (1999) and Mulholland et al. (2008). Only 9.4% of our sample of students belonged to different ethnic groups, which is a smaller proportion than in countries with a longer-standing multi-ethnicity (Evans, 2008; Kirkland, 1998). Belonging to different ethnic groups proved a risk factor for academic failure according to Salamonson and

Table 3 Factors associated with academic success (by multivariate analysis). Variables

Academic success (81/117) OR

IC95%

p-value

Age ≥26 years vs. b 25 years Distance of faculty from home ≥30 vs. b30 min Economic difficulties (yes vs. no) Life events while on the BNS course (yes vs. no) Failing at least one theory exam (yes vs. no) Failing one or more practical clinical assessments (yes vs. no) Family commitments (yes vs. no) Female vs. male Intention to leave the BNS course (yes vs. no) Ranking in entry exam 1st–40th vs. 41st or lower High school diploma vs. professional/technical/teaching diploma Previous university experience in other fields (yes vs. no) Hours worked per week while on the BNS course N16 h vs. ≤16 h/none

3.199 0.661 1.654 0.841 0.593 0.593 0.120 0.368 0.508 4.217 2.124 1.541 1.049

0.849 to 12.061 0.22 to 1.986 0.566 to 4.831 0.312 to 2.268 0.188 to 1.867 0.188 to 1.867 0.03 to 0.471 0.121 to 1.120 0.195 to 1.324 1.501 to 11.84 0.728 to 6.198 0.514 to 4.622 0.269 to 4.089

.086 .461 .358 .732 .372 .372 .002 .078 .166 .006 .168 .440 .945


Andrew (2006), while Mulholland et al. (2008) found it associated with academic success; in our study, it was neither positively nor negatively associated with academic outcome. The differences in the types of secondary education in different countries make it difficult to draw comparisons with reports in the international literature. In contrast with the findings of Ali et al. (2007), Van Rooyen et al. (2006), and Pryjmachuk et al. (2009), but in line with those of Mulholland et al. (2008), we found no association between the type of secondary education (technical/professional diploma vs. high school diploma) and the students' outcome on the BNS course. Our participants left secondary school with a mean 73.68 marks out of 100, which means a good level of schooling prior to joining the BNS course. As Stickney (2008) documented, higher marks at school are associated with academic success on subsequent degree courses. The participants' ranking in the entry exam for the BNS course was also associated with their final academic success. At least half of our sample (59, 50.4%) worked while studying on the BNS course, which is a smaller proportion than Salamonson and Andrew (2006) documented (78%), probably relating to differences in age, perceived economic difficulties and the need to support a family. According to Salamonson and Andrew (2006), working more than 16 h a week is associated with academic failure. It is important to consider the impact on academic outcome of so many hours of work, in addition to the 36 h a week considered mandatory for the BNS course. Patients may feel insecure if they are cared for by tired students, even if the latter are assisted by a qualified nurse. Students in our sample who recalled having had learning difficulties were more exposed to academic failure, and they failed several theory exams and practical clinical assessments. Most of our students (84.6%) failed at least one theory exam, for various reasons, e.g. lack of time spent on their studies due to academic or work overload, or travelling (many students spent more than 30 min travelling to and fro each day). Failing a theory exam was probably frustrating and interrupted the learning pathway, but it did not seem to be associated with academic failure, whereas passing the annual practical clinical assessment was more fundamental to academic success. Clinical training plays a key part for nursing students and a positive assessment keeps them motivated. Some participants (18.8%) reported having family commitments while on the BNS course (they were caring for children or elderly people) and this emerged as a factor related to academic failure at both univariate and multivariate analyses. Several authors (Cuthbertson et al., 2004; Steele et al., 2005) documented similar results. The time spent on family commitments probably reduces the time available for studying or attending lectures. In our sample, most of the students with family commitments were women (reflecting the prevalent Italian cultural model). One third of our participants said they had experienced financial difficulties but, unlike the case of Cuthbertson et al. (2004), and Steele et al. (2005), we found no association with academic failure. At least half of our participants had considered abandoning the BNS course. Some of their reasons have already been documented in the literature (Andrew et al., 2008; Destrebecq et al., 2008), e.g. personal problems, learning difficulties and troublesome relationships with teaching staff. This last reason is surprising, since the role of the staff is mainly to be supportive, as mentioned by Browden (2008). In the case of the BNS course considered here, this may be due to tutors having multiple roles, both assessing students in clinical settings and lecturing on theory courses due to a shortage of resources for nursing training. Factors relating to academic success or failure: multivariate analysis From the multivariate analysis, considering at least 13 factors that emerged at univariate analysis and mentioned in the international literature as being associated with academic success, only two factors

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revealed a statistically significant association with a positive academic outcome. Having no family commitments coincides with an at least 88% reduction in the risk of failure, while good marks in the entry exam mean a four-fold improvement in the chances of graduating within three years. This would mean that universities, potential students and professional nursing boards should adopt different strategies. The universities can offer part-time BNS degree courses (which are not available in Italy) to help mature nursing students, who are more likely to have family commitments. Potential students should be urged to prepare well for the entry exam by means of preenrolment courses provided by the universities with support from the student board. Improving the social image of nurses and circulating information on how much they contribute to patient outcomes, with the help of the National Nursing Board, might attract the best candidates to the BNS course and to the nursing profession. Conclusions Within the limited scope of this study, the academic failure rate documented is high: at least 3 in every 10 students enrolling for the BNS course failed to graduate. This high failure rate has a strong impact on the students themselves, their families, the faculties and the community, and becomes critical for countries such as Italy, where there is shortage of nurses. This study focused on the students rather than on factors relating to how the BNS course is organized. While nursing training pathways across Europe still differ considerably, under the Bologna Process (1999) and subsequent declarations, several countries are developing a common organizational framework. With this increasing standardization of nursing training, it may be worth defining a shared concept of academic success/failure, and measuring and comparing the associated factors, differences and similarities in the various countries. Understanding the factors on a local, national and European scale may facilitate the development of strategies to improve the academic success rate and the evaluation of the effectiveness of any action taken for this purpose. The priority of the universities is to prevent avoidable academic failure and contain physiological academic failure rates. The former demands a strongly proactive approach because it is associated with factors that prevent motivated students from completing their degree courses successfully; the latter concerns students enrolling for the BNS course without the necessary motivation and conviction, and/or with different aptitudes and talents. References Ali, P.A., Gavino, M.I., Memon, A.A., 2007. Predictors of academic performance in the first year of basic nursing diploma programme in Sindh, Pakistan. Journal of Pakistan Medical Association 57 (4), 202–204. Andrew, S., Salamonson, Y., Weaver, R., Smith, A., O'Reilly, R., Taylor, C., 2008. Hate the course or hate to go: semester differences in first year nursing attrition. Nurse Education Today 28 (7), 865–872. Browden, J., 2008. Why do nursing students who consider leaving stay on their courses? Nurse Research 15 (3), 45–48. Buchan, J., Seccombe, I., 2006. From Boom to Bust? The UK Nursing Labor Market Review 2005/06. Royal College of Nursing, London. Cuthbertson, P., Lauder, W., Steele, R., Cleary, S., Bradshaw, J., 2004. A comparative study of the course-related family and financial problems of mature nursing students in Scotland and Australia. Nurse Education Today 24 (5), 373–381. Dante, A., Valoppi, G., Palese, A. 2009. Fattori di successo e di insuccesso accademico degli studenti infermieri: revisione narrativa della letteratura. International Nursing Perspective 9, 45–52. Deary, I.J., Watson, R., Hogston, R., 2003. A longitudinal cohort study of burnout and attrition in nursing students. Journal of Advanced Nursing 43 (1), 71–81 24. Destrebecq, A., Destefani, C., Sponton, A., 2008. Abandonment of nursing courses: a survey regarding the motivations which lead the students to the abandonment of the nursing degree course. Professioni Infermieristiche 61 (2), 80–86. Evans, B.C., 2008. “Attached at the umbilicus”: barriers to educational success for Hispanic/Latino and American Indian nursing students. Journal of Professional Nursing 24 (4), 205–217. Federazione Nazionale Collegi IPASVI., 2005. Indagine sulla formazione universitaria degli infermieri. Rapporto anno accademico 2004/2005, Rome.

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Further Reading Law No. 2001, by the Minister for Education, University and Research and the Minister of Health “Determinazione delle classi delle lauree universitarie delle professioni sanitarie”, Rome. Law No. 2009, by the Minister of the Education, University and Research No. 4 August 2009, “Programmazione sei corsi di laurea disposta dagli atenei anno accademico 09–10”, Rome.