Introduction

There are presently, and impending increasing, shortages in the nursing workforce in many counties (USA [1], UK [2], Australia [3]). At the same time, enrolments into nursing programs are falling (USA [1], UK [2], Australia [4]). Improving the retention (or decreasing attrition), and increasing success (or decreasing failures), and increasing the enrolments of students in nursing programs are possible ways to increase nursing graduates.

Retention in nursing programs is poor and decreasing in some countries. Discussing retention, the American Association of Colleges of Nursing reported that the completion (retention) rates for nursing programs in the US.A. from 2021 to 2022 decreased [1]. In the UK, between 2014–2020, 13% of students in nursing did not complete [5]. The Australian government reported, in the latest university data, that the attrition rates for students in nursing increased from 2020 to 2021, where it was ~ 15%, and the six-year completion rates were the lowest on record in 2022 [4].

In nursing programs, there is evidence the students may have more problems in passing some courses (including the bioscience courses) than the clinical courses [6]. The factors contributing to this include the large body of facts that students must learn in the biosciences (anatomy, physiology, and pharmacology), poor study skills, and inappropriate entry requirements for science courses [6].

Worldwide, entry to university courses is still predominantly based on prior achievement levels/academic performance in educational institutions such as school or technical colleges. These achievement levels are usually higher for the more prestigious or demanding courses. A reason for using prior achievement levels as an entry requirement is that it is generally considered to be a predictor of success at university (e.g., health sciences, [7]).

Most studies of the predictors of success in nursing have been in programs, with little attention to courses. In reviewing, the predictors of nursing studies success in programs, Mthimunye & Daniels [8] showed that this included both academic performance measures and non-academic measures (e.g., older students, female gender, English language proficiency etc.). The academic performance measures that predict success include high admission Grade Point Average (GPA), high supplemental application score, high pre-admission science GPA [9]. In a review limited to the USA, Capponi et al., confirmed that both academic and non-academic program criteria predict success in nursing programs, with GPA being the most used criterium [10].

In the USA, the Test of Essential Academic Skills (TEAS) is a standardised, multiple-choice exam for entry into nursing, and higher scores predict higher GPAs during the program, and higher rates of graduation [11, 12]. The students with higher pre-admission GPAs had a higher chance of graduation [11, 13]. Science GPA and scores on the Health Educational Systems Incorporated Admission Assessment anatomy and physiology subscales are also predictors of success in nursing programs in the USA [13]. For the clinical courses in nursing, the scores in the Nursing Entrance Test (NET) Reading and Math components, remain predictors of success and retention in the USA [14].

In the UK, the number of General Certificate of Secondary Education (GCSE) Advanced levels obtained predicts success in a nursing degree [15]. Similarly, in Australia, when the University Admissions Index (UAI) was being used in New South Wales to rank Year 12 students, it was shown to be the best predictor of success in nursing programs [16]. Previous study of high school biology was associated with an increased bioscience course and overall GPA in nursing programs [16]. In New Zealand, it was shown that entry requirements for nursing had a higher correlation with academic performance in the first- than second-year bioscience course [17].

Worldwide there are several initiatives being undertaken to improve nursing student retention, success, and enrolments at university. Retention, success, and enrolments at university should not be considered in isolation, as they are not separate identities. One way to increase student enrolments, which has not been considered in detail, is to reduce the entry requirements. However, major considerations need to be given before doing this, as higher entry scores have been shown to predict more success, but also more completions and lower attrition rates.

Previous studies about retention and success in nursing have predominantly been in programs with little information on predictors in courses. From comparing the outcomes of students with the highest and lowest entry requirements in a program, it has been suggested that entry scores are a major predictor of both retention and success in nursing programs with students with the highest entry requirements having the best outcomes. The implication of this, is that dropping the entry score requirements for nursing students in programs will reduce retention and success.

However, none of the studies have directly considered what would happen to retention and success in program or courses if the entry requirements to programs were reduced. Thus, our research question is: Will dropping the entry score requirements have a major effect on retention and success rates for students in courses in a nursing program? At our Australian university, we have three campuses that run identical nursing programs. The only difference is that the entry requirements are lower in one than the other campuses. Our hypothesis was that the campus with the lower entry requirements would have lower retention and success rates. Thus, for individual courses at the lower- and at the normal-entry campuses, we measured and compared between campuses retention and success. Retention was measured as.

  1. (i)

    Overall completion rates and completion rates of student passing or failing.

  2. (ii)

    Students who could potentially progress or not from than course. The non-progression rate was defined as the combination of enrolled students who did not complete plus the completing students who failed, and for completing students we measured success.

  3. (iii)

    Academic outcomes; overall marks and marks for the exam and coursework

  4. (iv)

    Failure rates in the examination and coursework

As we wanted to ascertain whether our findings related to a variety of courses, analysis was undertaken for six courses.

Methods

Ethics approval and consent to participate

Ethical approval was obtained for this project from the University Human Research Ethics Committee (UHREC) at Griffith University (Gold Coast Campus, Parklands Drive, Southport, QLD 4222, Australia); Ethics Approval Number 2022/944. The UHREC is constituted and operates in accordance the National Statement on Ethical Conduct in Human Research (2007) and registered by the National Health and Medical Research Council (Australia). Under this approval from the UHREC, informed consent from individual students was waived. Student anonymity was achieved by removing names and students’ IDs from the marks data prior to the study. All methods were performed in accordance with the relevant guidelines and regulations of the UHREC.

Entry requirements for enrolment

In Australia, at the completion of secondary education, school leavers are given an Australian Tertiary Admission Rank (ATAR, 0 – 99.95; highest), which determines which courses they are eligible for at university. The ATAR is equivalent to the high school diploma in North America, and the General Certificate of Education (GCE) A Level in England and Wales.

The nursing degree at Griffith University is identical at three campuses. One of the campuses is in a low socio-economic index area (SEIFA) whereas the other two are in high SEIFAs [18]. To obtain sufficient enrolments to run the program on the campus in the lower SEIFA, it has a ‘lower’ entry requirement than the other two high SEIFA campuses, which had the ‘normal’ entry requirement. Thus, in 2022, the ATAR was 81 in the lower SEIFA (‘lower’ entry requirement) and 86 in the high (‘normal’ entry) and in 2021, 78 vs 82, respectively.

Study design

The design is a descriptive and comparative study of the outcomes for the students in nursing at three campuses with different entrance requirements: two campuses with normal-entry and one campus with lower than normal-entry. As the results from the normal-entry campuses were identical, we chose to only present the data from one campus, which was randomly chosen. To be able to include data from all the students in each course, we obtained a waiver from seeking consent (previous section).

Research setting

The research was undertaken in an Australian university, where students are typically required to achieve an overall mark of 50% to pass a course and passing grades are 4 (overall mark, 50–64%), 5 (65–74%), 6 (75–84%) and 7 (≥ 85%). In all courses, students with < 50% of the overall marks failed, and in the clinical courses, students who did not undertake the clinical placement, also failed.

Participants

Almost all the students undertaking the courses in Anatomy & Physiology (A & P) have entered the Bachelor of Nursing program directly after completing either secondary school education with ATAR scores or tertiary enabling/preparation courses. The tertiary enabling course at Griffith university (EmpowerED University Preparation Program) is for students who do not meet the formal admission requirements. Success in this program, and subject to the English language requirements, students can undertake the Bachelor of Nursing.

Students with a Diploma of Nursing (Enrolled) nurses from Australia and Internationally Qualified Nurses are given credit in recognition of prior learning in the A & P courses, and do not undertake these courses. These students are known as Advanced standing students.

After completion or credit for the A & P course, the students (direct entry and advanced standing entry) undertook two courses in Human Pathophysiology and Pharmacology (Path & Pharm 1 and 2) and clinical courses in Chronic Illness Management (Chronic illness) and Mental Health Nursing Practice (Mental health).

After census date (i.e., last date when students can withdraw without financial penalty), between 62–77 students were enrolled in the courses at the lower entry score campus and between 174–288 were enrolled at the normal entry score campus (Table 2).

Courses

The courses chosen were to represent different stages of the BNursing program and participants. Thus, the A & P courses were chosen to represent the early stages of the program with only direct entry students. The Path and Pharm courses were chosen to represent the mid-year of study with both direct entry and advanced standing students. The clinical courses were chosen to determine whether there were differences between the findings for Path and Pharm bioscience courses and clinical courses for all students. Details of the courses (semester, pre-requisites, method of teaching, assessment) are given in Table 1.

Table 1 Course prerequisites, method of teaching, and assessment
Full size table

Marking

Marking was not limited to the staff that taught at each campus. It was distributed among staff from all campuses to help nullify any differences between markers.

Data collection procedures

The author was not involved in the teaching and marking of any of the courses. The coordinators of the nursing courses gave their permission to the Nursing program co-ordinator to provide a copy of the Microsoft Excel sheets of the marks associated with the courses to the author. The data was from semesters 1–4 in 2022 and was the starting point for the following analysis. Mean values, and Student’s unpaired tests were performed using the data analysis function in Microsoft Excel. In the analysis, P ≤ 0.05 was considered significantly different.

Retention in individual courses

For each course, the data at the lower- and normal- entry levels were compared using the Odds ratio. The Odds ratio is the odds that an outcome will occur with a particular exposure (in this case, the lower-entry requirement) compared to the odds of the outcome occurring in the absence of that exposure (normal-entry requirement). The larger the Odds ratio, the more likely there is a difference. When the 95% confidence interval (CI) of the Odds ratio does not include 1.0, the Odds ratio indicates a significant difference between groups. The Odds ratios were calculated using the online Odds ratio calculator, https://www.medcalc.org/calc/odds_ratio.php. [19], which provides computation notes, and gives the Odds ratio, 95% CI, z statistic, and Significance level (P value).

  1. (i)

    Data analysis for students enrolled on census date who withdrew early.

The number and percentage of students enrolled on census date who withdrew early from each course was tabulated.

  1. (ii)

    Students enrolled on census day who completed with passing or failing.

For those who were enrolled on census day, the number/percentage of students who completed and passed or failed were tabulated. Some of students who failed after census day may have done so because they were considered to have completed, as they had not formally withdrawn.

  1. (iii)

    Non-progression rates

The numbers of students who could not progress in, or complete the program, defined as the combination of enrolled students on census day who withdrew early and of students who completed but failed, were also tabulated. These students could not complete the program until they had passed this course. In addition, of the courses studied, students who did not pass the Path & Pharm 1 course could not enrol in the Chronic Illness course (Table 1).

Success in courses

The assessment and weighting of the assessment in each course is given in Table 1. The methods for measuring success in courses (percentage of students who obtained ≥ 5 0% of marks overall) has been described previously [20].

Success: For the students enrolled on census date who completed, data analysis comparing overall academic performance, and performance in coursework and the exam

The marks for the combined coursework, the components of the coursework, and the exam were totalled, the total expressed as a percentage, and then the percentages were averaged. Mean values ± SD were also determined. For each course, the percentages at the entry levels were compared using Students unpaired t-test.

Success: For completing students, data analysis comparing failure rates in examination and coursework

Students who achieved less than 50% in the coursework, or the exam, were considered to have failed that component. The failure rates for each component were compared by Odds ratio between the entry levels.

Results

Results are from 2022. As the results of the study were identical for the two campuses with normal-entry requirements were identical, the results of only one of these is presented.

In any year, first year school leaver/tertiary enabled students undertake A & P 1 and 2. At the same time, second-year full-time students (school leavers/tertiary enabled in 2021 and advanced standing students in 2022) undertook Path & Pharm 1 and 2, and the clinical courses.

Retention: students enrolled on census date who withdrew early, students enrolled on census date who completed with passing, and non-progression rates

The numbers and percentages of these are given in Table 2. Between the entry requirement levels, odds-ratio analysis with P values are shown (Table 2).

  1. (i)

    The students enrolled on census date who withdrew early were similar for each course, except the Mental health course. In the Mental health course, the students who withdrew early was significantly higher in the normal- than lower-entry campus by 4% percentage points.

  2. (ii)

    The passing rates for completing students enrolled, on census date, were similar in bioscience courses. For the clinical courses, the passing rates for completing students were significantly higher by 8–11% points in the normal- than lower-entry campus.

  3. (iii)

    The non-progression rates (the combination of enrolled students who withdrew early and of completing students who failed) were similar for all courses.

Table 2 Number and percentage of enrolments on census day, and students enrolled on census date who withdrew early, student who completed with passing or failing, and non-progressing students in each course
Full size table

Success: For the students enrolled on census date who completed

The mean percentage marks ± standard deviation in examination and coursework are given in Table 3.

Table 3 Percentage marks in examination and coursework for completing students
Full size table

Between the entry requirement levels, unpaired t-test comparisons with P values showed that in the bioscience courses (Table 3).

  1. (i)

    The overall marks, combined coursework marks and quiz marks were similar in the bioscience courses.

  2. (ii)

    The marks for the concept maps were similar in both Path and Pharm courses. The written assignment marks were also similar in the A & P 2 courses.

  3. (iii)

    In the A & P 1 course, the written assignment mark was significantly higher in the cohort with lower- than normal-entry requirement by 6.2% points.

Between the entry scores, unpaired t-test comparisons with P values showed that in the clinical courses (Table 3).

  1. (iv)

    The overall mark for students in the Chronic illness course, was significantly less in the lower- than normal- entry cohort by 3.8% percentage points. This was due to significantly lesser marks in the coursework marks due to a lesser mark in the clinical simulation component by 10.5% points.

  2. (v)

    In the exam and written assignment, there were no significant differences in marks.

  3. (vi)

    The marks for the coursework were also similar in the Mental health course.

Success: failure rates for students, enrolled on census date, in overall marks, and its components

Between the entry requirement levels, in the bioscience courses, Odds ratio testing with P values, showed (Table 4):

  1. (i)

    The overall failure rates were similar.

  2. (ii)

    In exams, the failure rates were similar.

  3. (iii)

    In the combined coursework, there were no differences in failure rate for the A & P 1, and Path & Pharm 1 and 2.

  4. (iv)

    The failure rates for the combined coursework were significantly greater for the lower-than normal-entry students in the A & P 2 by 11.6% points. This lower coursework mark was due to the lower-entry cohort having greater failure rates in both the quizzes and the written assignment by 8.2% and 7.8% points, respectively.

Table 4 Failure rates in examination and coursework for completing students
Full size table

Comparison in the clinical courses by Odd-ratio testing showed that failure rates were greater in the lower-than normal entry cohorts, which was either a significance or a trend (Table 4). Thus:

  1. (i)

    The overall failure rates were significantly greater for the lower- than normal- entry cohort in the clinical courses by 11.0% and 7.3% percentage points in the Chronic illness and Mental health courses, respectively.

  2. (ii)

    In the lower- than normal-entry cohort, the failure rates in the exam were greater in the Chronic illness course by 6.7 percentage points but this did not reach significance. The failure rates in the Mental health course were similar (0.8 percentage difference).

  3. (iii)

    In the Chronic illnesses course, the failure rates for the combined coursework were significantly greater for the lower than normal-entry students by 17.5% points. This was due to the lower entry cohort having greater failure rates in both the clinical simulation and written assignment by 17.7% and 11.8% points, respectively.

  4. (iv)

    In the Mental health course, there were no significant differences in failure rates in coursework.

Discussion

In summary, there are more similarities than differences in retention and success rates between entry levels, and the differences did not always favour the normal- over lower-entry campus:

  1. (a)

    For five of the six courses the students enrolled on census date who withdrew early were similar. In one clinical course, the early withdrawal rate was higher in the normal- than lower-entry campus.

  2. (b)

    For all courses, the progression rates were similar.

  3. (c)

    For the bioscience courses, the passing rates for completing students were similar, whereas in the clinical courses, the passing rates for completing students were higher in the normal- than lower-entry campus.

  4. (d)

    In the bioscience courses and Mental Health course, the overall marks, combined coursework marks and quiz marks were similar. The marks for the written assignment were higher in the campus with lower- than normal-entry requirements in the A & P 1 course, but similar in the other bioscience courses and Mental Health course.

  5. (e)

    In the Chronic Illness course, the overall mark was slightly less in the lower- than normal-entry cohort but there were no differences in the exam and written assignment marks.

  6. (f)

    The overall failure rates were similar for the biosciences, but greater for the lower- than normal-entry cohort in the clinical courses. The failure rates in exams were similar between cohorts in all courses.

This summary shows little support for our hypothesis that the campus with the lower-entry requirements would have lower retention and success rates. Thus, the differences between the campuses with normal- and lower-entry requirements were few and small. Importantly, these differences were not detrimental to the lower-entry cohort in retention measured as early withdrawal rates or non-progression rates in all courses. The differences in entry requirements also did not affect the success of students, measured as either overall marks or overall failure rates in the bioscience courses.

In our study we measured retention and success from individual courses, not from a program. This a major difference from most previous studies, which related entry requirements to measures of retention, and success for the top- and bottom-entry marks from a program, without considering the students with middle-entry requirements. This makes a direct comparison not possible for several reasons, including that we included all students in each course. Thus, in this discussion we initially consider our results as stand alone, and then we make an indirect comparison to previous studies.

In considering students from two campuses in our study, difference in completion rates could potentially have affected the success/ academic outcomes of completing students. For instance, if the completion rates were higher or lower at one campus than the other, this could have biased the sample of the completing students to change the success rates/ academic outcomes of the completing students. Thus, in a course with a lower completing rate, this may be associated with a loss of the less able students and could increase the success rates academic outcomes of the completing students. However, in the present study, the completion rates were similar for all the bioscience courses, and one of the clinical courses. Thus, completion rates could not be a major factor in any differences between success/academic outcomes in the courses with similar completion rates.

However, bias may have been a factor in differences for completing students in one of the clinical courses (Mental Health), where the completion rate was slightly less for the students with the normal- than lower-entry requirements. This could have led to higher passing and lower failure rates, and this was the finding associated for the normal- than lower-entry completing students. However, there was no difference in the overall marks and marks for the exam and coursework for the completing students between the cohorts in this clinical course. This shows, if they did have an effect, that small differences in completion rates did not have major effects. Again, this illustrates very modest difference in retention and success with lower-entry requirements.

In our study, the overall non-completion rates were similar between entry requirements in the bioscience courses, and the Chronic Illness course. In contrast, in the Mental Health course, the overall non-completion rates were higher in the normal- than lower-entry cohort. It is worth noting that the difference in non-completion rates between the normal and lower-entry cohorts in the Mental Health course favours the lower-entry cohort, who had higher completion rates than the normal-entry students. This emphasises that not only did differences occur in a small number of the parameters of retention and success that we measured but, that the differences did not always favour the normal entry requiring campus.

It is possible that entry-requirements (e.g., ATAR scores) are more likely to predict outcomes in the initial than later courses of a program, as these initial outcomes will be prior to exclusion of students who do not complete or failure. In this study, there were several parameters that we measured that were similar between the different entry requirements in the bioscience courses. These included early withdrawal rates, progression rates, overall marks, and failure rates. As these similarities occurred in both A & P courses, which are in the first year of the program, they strongly suggest that the small difference in entry scores between campuses had no effect on effect on the academic performance at this stage of the program.

Although selected for their differences in entry levels, it was noted that the campuses were in different SEIFAs. SEIFA has a scale of 1 to 5, with 5 being the highest social economic index. The lower- than normal-entry level campus was in area 2, whereas the normal-entry was in the highest area (scale = 5, [19]). This may suggest that lowering entry requirements to a small extent in areas of lower social economic index does not affect outcomes in bioscience courses. Thus, lowering entry levels in area of low social economic index requires further exploration as a method to increase the number of students in nursing.

In contrast, to the results in the initial bioscience courses there were a few parameters that we measured that favoured the normal- over the lower-entry requirements in one or both clinical courses. These differences included completion with passing or failing rates, overall marks, combined coursework marks, and quiz marks. The reason for this is unknown, but it may not be related to entry requirements, as the students were already in their second semester of second year when undertaking the clinical courses (Table 1). One possibility is that, as they were students in nursing, they may have had a higher aptitude for clinical than bioscience courses. This possibility is supported by the finding that in the same semester (4th semester), there were few differences between the normal- over the lower-entry requirements in the bioscience course (Path & Pharm 2) but the outcomes were better for the normal- than the lower-entry requirements in the clinical courses. Previous studies have also suggested that students in nursing have better outcomes in clinical than bioscience courses [6].

Another reason may be that the clinical courses have different populations of students enrolled. The enrolments in the A & P courses were mostly school leavers whereas advanced standing students joined in the Path & Pharm 1 course, and then went on to undertake the clinical courses. As there were no difference in the retention and success rates between entry requirement levels in the Path & Pharm 1 and 2 courses, it seems unlikely the inclusion of advanced standing influenced the outcomes in these courses.

At Griffith University, there are two campuses with normal-entry and one with lower-entry. We did undertake a full analysis of both normal-entry campuses, and there were no differences between them, and consequently we presented data from one of them that was randomly chosen. That there were no differences between the two normal-entry requiring campuses verifies that the program is identical on the two campuses and suggests that the small differences between the normal- and lower-entry campuses presented here are real.

Our results from all the students in individual courses are difficult to compare to results from previous studies comparing highest- and lowest-entry students within courses or in programs discussed in the Introduction. These previous studies have probably not surprising suggested that higher entry scores are clearly associated with better retention and success in either a course or a program. Possible explanations for this difference with our study is that, previous studies have been within one course or one program and have compared the students with the highest and lowest entry marks for retention and success within that course/program and shown the students with the highest entry marks had the best retention/success [8, 15, 16]. Typically, studies have compared the of students in a program from the top-half to the bottom-half of entry qualifications, and consequently, the differences in the entry scores for the groups will be large. If we had done this, we might have confirmed previous results. However, we compared all the students in identical courses at two campuses with only small differences in overall entry requirements, rather than the top and bottom entry students in a single course. A second explanation for the difference between our study is that, not only did the present study use a different protocol to previously, but also looked at much smaller differences in entry requirements: 5 and 4 points on the ATAR scale in 2021 and 2022, respectively. With this small difference, we did not find a clear-cut difference between those students who overall had met a lower- than at the other normal-entry requiring campus.

Implications

The finding of this study has implication for enrolments in nursing, which are falling, while requirement for nurses in increasing. Thus, undergraduate enrolments in the U.S.A. have been declining since 2011/12 [1]. The American Association of Colleges of Nursing have reported that enrolments in nursing declined by 1.4% or ~ 3,500 students from 2021 to 2022 [1]. In the future, the increased requirements for nurses will far outstrip the supply [1]. In the UK, the Nursing Times reported that undergraduate enrolments in nursing are down 12% [1]. In the UK, the present shortfall in registered nursing in the NHS workforce is over 40,000 and government attempts to recruit more nurses have failed [21].

In line with overseas trends, the Australian government reported in the latest university enrolment data that the number of enrolled domestic students declined from 2021 to 2022. In nursing, there was a 10% reduction in enrolments between 2018 and 2022, which predominantly occurred between 2021 and 2022. In addition, the attrition rates for nursing students increased from 2020 to 2021, where it was ~ 15%, and the six-year completion rates were the lowest on record in 2022 [4]. It is projected that Australia will face a shortage of over 100,000 nurses within the next three years [3].

This study suggests that the entry requirements for students in nursing can be lowered without major effects on retention and success. This may be a way of increasing enrolments and graduates in nursing.

Limitations

As we did not get consent from individual students, our study is not following students as they progress through the program. Rather the data is from all the students in the courses that ran in 2022. This allowed us to include all students in each of the courses, rather than limiting the study to consenting students. The downside of this is that we cannot relate entry requirements for individual students as they progress through the program to their retention and success.

The students in the A & P courses were secondary school leavers or equivalent, who were joined by Advanced standing students for the Path & Pharm and clinical courses. We also did not have information from the students as to whether they were school leavers or advanced standing students. This information may have been a useful addition to the study. Consequently, we asked the University for this information in numbers to fit with the ethics waiver. However, this information is not available for individual courses, only for the programs.

The major strength of this study was that it included courses that were identical between campuses/cohorts, which made it a direct comparison between entry-levels requirements. This contrasts with previous studies that have predominantly compared students with higher and lower-entry qualifications in the same program. Another strength was that the study included both bioscience and clinical courses, whereas most previous studies of courses have been in the biosciences. Finally, the study was investigating differences at course level between entry-level scores in a single program.

Conclusions

This study, which is limited to one program at one school, suggests that small changes in entry requirements for a nursing program had minimal effects on retention. The differences in entry requirements also did not affect the success of students in the bioscience courses. Decreasing entry requirement for nursing programs may be a way to increase nursing graduates.