Pedagogical challenges in nurse education - a case study focusing on the completion rate in theoretical education at a Swedish University
© Emilsson et al.; licensee Springer. 2014
Received: 23 February 2014
Accepted: 23 October 2014
Published: 25 November 2014
The purpose of this survey was to relate completion rate and results on national clinical final examinations to student’s admission background and examination results for nursing and medical courses.
The research data were based on a quantitative case study, with 286 nursing students, using statistical analysis.
The programme’s overall completion rate was 76%, i.e. almost one out of four students did not complete the programme. The higher students’ upper secondary/high school grades, the fewer attempts they needed to pass the nursing and medical courses exams (p < 0.001). The average examination attempts needed to pass courses in medical science was significantly greater than the number needed to pass courses in nursing science (p < 0.001). In a multivariate analysis both upper secondary/high school grades and average examination attempts needed to pass were significant predictors for national clinical final examination score.
In sum, upper secondary/high school grades and examination attempts needed, especially for courses in medical science, may be regarded as important indicators of achieved knowledge and skills which are tested in the national final examination.
Demand for nurses in Sweden is strong, making it crucial that nursing students are provided the best possible conditions for completing their education, irrespective of background and experience. National and local education aims require that graduated nurses attain a level of skills appropriate for current and future healthcare needs (SFS ; Socialstyrelsen ). In order to ensure that a student in a nursing education programme reach such clinical competence it is essential to study potential predictors for successful completion. The objective with this study is to relate completion rate and results on national clinical final examination tests to student’s admission background and examination results for nursing and medical courses.
Swedish nurse education has undergone several changes due to developments in society and in healthcare services. In the 1950s-60s, nurses were expected to possess technical and scientific knowledge; in the 1980s, their knowledge was expected to be based on nursing science and a holistic view of the individual (Furåker ).
Since 1993, the nursing education programme is a three-year higher education programme, providing a professional qualification and a Bachelor’s degree in nursing (SFS ). At the same time, the nursing education programme admission criteria changed: students were no longer required to have previous nursing experience to apply for admission (Furåker ).
With the academisation of nursing education programmes, the nursing subject, in both Sweden and in Europe, has received an increasingly important role and is expected to present a clear structure with a theoretical base and progression (Laiho ; SSF ). Additionally, nursing courses are expected to integrate closely with other support subjects such as ethics, biomedicine, public health and pedagogics (SSF ). A review of the curricula of nursing education programmes reveals that medical science is the most common support subject for nursing science. The scope of the medical subject, in relation to nursing, varied from 30 to 67.5 of the nursing education programme’s overall 180 university credits (Ohlén et al. ). Previous research (Lilja Andersson ) has found that nursing students express concerns about the content of the two subjects nursing science and medical science. Students initially felt that the medical subject was presented in a fragmentary manner and was difficult to combine with understanding of the functions and illnesses of the human body. The medical subject felt abstract and was difficult to discuss as it seemed to be merely a mass of details to be memorised. The nursing subject was also, initially and sometimes during the education, perceived as being diffuse and abstract with a dissonance between the factual knowledge and the underlying philosophical assumptions.
Since 2007, 16 of Sweden’s 25 nursing education programmes have been using the Swedish National Clinical Final Examination (NCFE). The purpose of this examination is to test whether the student has achieved the clinical competence expected of newly graduated nurses as per university and The National Board of Health and Welfare regulations (SFS ; Socialstyrelsen ). The NCFE comprises a practical and a theoretical individual examination carried out during the nursing education programme’s last term (www.nkse.se). In the theoretical part, the student is expected to describe and explain own actions based on a patient case, thus showing ability to integrate the theoretical and practical knowledge gained during the nursing education programme. Students highlighted that the NCFE gave them greater confidence and awareness of their clinical competence (Lilja Andersson et al. ).
To be accepted as a student at a Swedish nursing education programme a candidate must have achieved complete and passing upper secondary/high school (a three-year curriculum) grades, including higher level English, mathematics, civics/social studies and natural sciences. This qualification can be achieved either through an upper secondary/high school programme (offering theoretical and more vocational programmes), directly following elementary/grade school, or through a folk high school programme. Alternatively, candidates can sit the Swedish Scholastic Aptitude Test, which may qualify for admission. Candidates for the nursing education programme are ranked according to their upper secondary/high school grades or their Swedish Scholastic Aptitude Test score (www.sjuksköterska.nu; www.studera.nu).
In this study the nursing education programme at a Swedish university is studied. The programme’s main subject, nursing science, is characterised by its holistic view of man and a scientific and ethical approach. Medical science is a support subject of nursing science and covers anatomy, physiology, illness and the treatment thereof. The nursing subject represents 135 of the programme’s 180 university credits, with the medical subject representing the remaining 45 credits.
When it comes to the knowledge production and learning objectives in the programme both theoretical and practical knowledge is emphasised. Theoretical knowledge gained through formal learning is many times expressed as theories of general validity, while practical knowledge developed through informal learning constitutes a basis for being able to act in specific situations. In nurse education, there is often a tension between the ambitions to integrate theoretical knowledge with practical knowledge, and one challenge for nurse education is to elaborate a way to satisfy educational needs, workplace needs and, above all, students’ needs (Newton et al. ).
As nursing education programmes at Swedish universities receive government funding in accordance with the number of students who pass the national clinical final examination and complete the entiry nursing education programme, it is of course desirable for universities to keep the dropout rate as low as possible and to achieve the highest possible results in terms of clinical competence, programme completion, and national clinical final examination scores. Naturally, students share this ambition, as they do not want to invest time and effort into the programme without reaching completion.
To study potential relationships between completion rate and student’s admission background and examination results for nursing and medical courses.
To study potential relationships between results at the national clinical final examination and student’s admission background and examination results for nursing and medical courses.
Admission qualifying education and admission points for the study population (n = 286, missing information for 2 students)
Upper secondary/high school credits
Scholastic aptitude test points
Scholastic aptitude test points with work experience
Folk high school credits
Number (%) (max-min)
n = 144 (50.35%) (0.97-22.50)
n = 110 (38.46%) (0.10-2.00)
n = 25 (8.74%) (0.10-2.00)
n = 5 (1.75%) (1–4)
Data and data collection
The data comprised the examination results from all theoretical nursing and medical science courses. The nursing science courses changed slightly for the three admission classes in the course of the nursing education programme, whereas the medical science courses remained unchanged throughout the studied period. The students’ examination results during the programme were compared with their results on the NCFE at the end of the programme.
Data collection was done during the 2012 spring term from the Swedish higher education study administration system and from the admissions board. This system stores data on the individual student’s sex, age, qualifying upper secondary/high school education, examination attempts and examination results. Swedish Scholastic Aptitude Test points were only available for students admitted based on said points with or without working experience. Likewise, the upper secondary/high school grades were only available for students in the upper secondary/high school admission group. Information about the number of examination attempts needed to pass a course was collected for each individual course. Moreover, the number of examination attempts needed to pass was calculated for each individual student on an aggregated level. For each year, and for each student, the average number of examination attempts needed to pass was calculated for the group of courses in nursing and medical science separately. For instance, if a student has a value of 1.2 for nursing courses in Year 2, that students had to make on average 1.2 attempts for the completed nursing courses in Year 2. For each student the average examination attempts needed to pass per year and the overall average examination attempts needed to pass, including all courses passed, were also calculated. For instance, if a student has 1.5 in average overall examination attempts needed to pass, it means that the student had to make on average 1.5 attempts to complete the courses. Qualifying education information (grades/points) was obtained from the admissions board. Admission was granted based on either of the following criteria: upper secondary/high school grades; Swedish Scholastic Aptitude Test points; Swedish Scholastic Aptitude Test points with work experience; and folk high school credits (1–4). Admission distribution over these categories and descriptive statistics for grades and Swedish Scholastic Aptitude Test points are given in Table 1.
The upper secondary/high school grades did not differ significantly between males and females (average 16.3 vs 15.6, p > 0.20), and there was no significant correlation between upper secondary/high school grades and age (r = 0.1, p > 0.20). The upper secondary/high school grades did not differ significantly between the different upper secondary/high school grades groups (nurse auxiliary group: average 15.8, vocational but not nursing group: average 15.2, theoretical group: 15.9, p > 0.20). There was no significant difference in Swedish Scholastic Aptitude Test points between males and females (average 0.62 vs average 0.70, p > 0.20) and there was no significant correlation between age and said points (r = 0.2, p = 0.11). The Swedish Scholastic Aptitude Test points did not differ significantly between the different upper secondary/high school grades groups (nurse auxiliary group: average 0.6, vocational but not nursing group: average 0.5, theoretical group: 0.7, p = 0.13).
Data privacy and ethical considerations
Data was coded and personal information was treated confidentially. Only those responsible for the study had access to data and personal information. Coded data and personal information were stored separately. During the analysis data was de-identified, i.e. names and civic registration numbers were removed. The results have been presented in such a manner that individuals cannot be identified (Vetenskapsrådet ). This study was approved by the University West Ethics Committee.
For analysing relationships between categorised data, the classical chi-square test was used. For comparing two or more groups for continuous data, standard t-test or ANOVA was used. However, in the case of small samples and skewed distribution, the Mann–Whitney-U’s test or Kruskal-Wallis test was used instead. When analysing differences between courses (nursing vs medical science) comparisons of examination attempts needed to pass were analysed for each student by applying Wilcoxon’s signed-rank test. When analysing the potential relationship between continuous variables Pearson (r) or Spearman (rs) correlation was used dependent on distribution shape. When studying relationships between the national test result and potential predictors, the significant predictors found in the bivariate analyses may be inter-correlated. In order to study the significant variables simultaneously a multiple regression model was adopted, including all explanatory variables that were significant in the bivariate analyses. The variance inflation factor was used to diagnose potential problems with mutlicollinearity. Generally, a significance level was set to 5%. Due to the fact that the study is of an exploratory nature and that many tests were performed, significances should be interpreted with care and regarded as interesting findings rather than as conclusive evidence (Altman ). IBM software SPSS 20.0 was used for all analyses.
Out of the study population’s 286 students, 218 (76%) had completed their education at the time of the study in the spring of 2012. The remaining students (n = 68, 24%) had not at the time of data collection completed their education due to either failing examinations or changing study location. The students (85%) who had achieved their degree completed their studies within the nursing education programme’s time frame (3 years).
Proportion completers, by gender, admission group and upper secondary/high school education
Admission group (excluding FHS and transferred)
USHS education group
Vocational but not nursing
Within the group admitted based on upper secondary/high school grades, there was a significant difference in upper secondary/high school grades, as the median was 15.5 among completers and 14.8 among non-completers (p = 0.031). However, in the group admitted based on Swedish Scholastic Aptitude Test points, there was no significant difference between non-completers and completers (the mean was 0.72 and 0.76, respectively, p > 0.20).
In Year 1, the completion rate was 263 out of the 286 admitted students (92%). Among the 23 Year 1 non-completers 20 failed at least one nursing course and 20 failed the medical course. Among the 263 first year completers 249 managed to complete Year 2. Thus, the risk of not completing Year 2 among the Year 1 completers was 5%. Among the 14 non-completers Year 2, 10 had failed at least one nursing course, and 10 had failed at least one medical course. Among the 249 who completed Year 1 and Year 2, 31 (12%) did not complete Year 3. Among these non-completers all had failed at least one course and 21 had not completed their student thesis.
Examination attempts needed – differences between courses
Number of attempts needed to pass a course, nursing vs medical science
Average number of attempts needed to pass courses in
Nursing science mean (median)
Examination attempts needed - differences between students
The overall average number of examination attempts needed to pass varied from 1.0 to 2.2, with a mean of 1.3 (median 1.2, st.dev 0.3). The mean was 1.3 for both males and females. There were no significant differences between admission groups, neither between different upper secondary/high school groups. There was no significant correlation to age. There were, however, significant correlations between the overall average examination attempts needed to pass and upper secondary/high school grades (rs = –0.4 , p < 0.001) and Swedish Scholastic Aptitude Test points (rs = –0.4, p < 0.001), indicating a decreasing number of attempts needed with increasing upper secondary/high school grades and Swedish Scholastic Aptitude Test points. The overall average number of attempts needed was 1.2 among students who completed the programme, as compared with 1.4 among non-completers (p < 0.001).
National Clinical Final Examination
To pass the National Clinical Final Examination (NCFE) students had to score at least 33 of 50 possible points. Of the study population’s 286 students 219 (76.6%) attempted the NCFE of which 20 (9.1%) failed the examination. The average score was 36.2 points (SD 4.0). Among the 68 students without a complete nursing education programme 13 attempted the NCFE of which 9 passed (69%). The proportion of approved tests among the completers was significantly higher (92%, 190 out of 206), p = 0.005. There was no significant difference in average NCFE score between males and females, and no significant correlation between NCFE score and age. There were no significant differences in NCFE score between admission groups, or between different upper secondary/high school groups. There was a significant correlation between upper secondary/high school grades and NCFE score (r = 0.3, p < 0.001), but not between Swedish Scholastic Aptitude Test points and NCFE score (r = 0.0, p > 0.20).
Correlation (r s ) between NCFE score and the average number of attempts needed to pass courses in nursing/medical science and total per year
–0.3 (p < 0.001)
–0.2 (p = 0.002)
–0.3 (p < 0.001)
–0.1 (p > 0.20)
–0.4 (p < 0.001)
–0.4 (p < 0.001)
–0.2 (p = 0.023)
–0.2 (p = 0.006)
–0.2 (p = 0.013)
Results from multiple regression, with NCFE score as independent variable and completion, upper/secondary high school grades and average examinat ion attempts needed to pass as explanatory variables
Model summary (n = 108)
F-test (df = 3,105)
F = 9,3 (p < 0.001)
Completer vs non-completer
Upper/secondary high school grades
Examination attempts needed to pass
In an exploratory manner, we also replaced overall examination attempts needed to pass with examination attempts needed to pass by year and type of course and found that the original bivariate analyses were stable, significant correlations between examination attempts needed to pass and NFCE score remained.
The overall completion rate for the nursing education programme was 76%, i.e. almost one out of four students did not complete the programme. Figures from the Swedish National Agency for Higher Education () show that about one fourth of those failing to achieve their degree within a nursing education programme changed their place of study. Previous studies have shown that several factors can affect the study situation negatively and lead to defection, e.g. stress in the course of the programme (Timmins et al. ), stress in relation to examinations and assessments in the programme’s practical and theoretical courses (Howard ), high work load, many study hours and too little leisure time (Pryjmachuk and Richards ; Watson et al. ) and difficulties in bridging the gap between the programme’s contents and the expectations of the healthcare organisation (Duchscher ). In our data the dropout rate Year 1 was 8%. Among the remaining students who completed Year 1 and continued 5% dropped out Year 2. As mentioned above, some of the dropouts the first two years may be students changing study location. However, among students who managed to complete the first two years, the dropout rate in Year 3 was 12%. All of these dropouts had completed at least one course and a majority had attempted other courses. Thus, the explanation for non-completion the last year may be due to the other reasons described above. Two out of three of the non-completers Year 3 had not completed the student thesis.
Regarding background variables at admission, neither gender, age, Swedish Scholastic Aptitude Test points, admission group, nor upper secondary/high school education group (nursing, other vocational or theoretical) were significantly related to completion. However, there was a difference in upper secondary/high school grades between completers and non-completers. It has previously been claimed that upper secondary/high school grades is one of the best admission criteria (Wedman ). However, the difference between the completers vs non-completers was only 0.7 and the standard deviation for upper secondary/high school grades was 1.6, indicating a large overlap in upper secondary/high school grades between completers and non-completers. Thus, upper secondary/high school grades may not be that predictive, at least not on an individual level.
Number of examination attempts needed to pass
The average number of examination attempts needed to pass was used for studying differences between students and between courses.
Regarding differences between groups of students we did not find any significant relationships between examination attempts needed to pass and admission group, upper secondary/high school education, gender or age. However, the upper secondary/high school credit and the Swedish Scholastic Aptitude Test point were both significantly related to the average examination attempts needed to pass, showing that an increase in upper secondary/high school grades/Swedish Scholastic Aptitude Test points goes hand in hand with a decrease in examination attempts needed to pass. In other words, students with higher grades/points at admission do not as many examination attempts as students with lower grades/points. The magnitude of the correlations (rs = –0.4) could be classified as moderate (Cohen ). Regarding differences between courses we found a difference between courses in medical science compared to courses in nursing science. Medical courses demanded on average 0.4 more attempts to pass. As a comparison, the difference between non-completers and completers was 0.2 in overall average examination attempts needed to pass. Thus, the difference between medical and nursing science courses is twice as high.
National Clinical Final Examination
Out of the 219 students who attempted the National Clinical Final Examination (NCFE), 20 (9.1%) failed. Regarding the second objective of the study, i.e. to investigate explanatory factors possibly related to NCFE scores, the pattern was consistent with the pattern for completion rate. Among the background variables at admission, neither gender, age, Swedish Scholastic Aptitude Test points, admission group, nor upper secondary/high school education group (nursing, other vocational or theoretical), were significantly related to NCFE score. However, upper secondary/high school grades were moderately (rs = 0.3) correlated to NCFE score. The information received successively during the nursing education programme was found to give valuable added information. We found that the average number of examination attempts needed to pass was correlated to NCFE score both on an aggregated level, e.g. by year, but also for some specific courses, i.e. one general nursing course and three medical courses (Clinical Medicine in Physical Ill-Health and Drug Calculations I and II). Several of these correlations reached a magnitude of 0.4 which may be regarded as a moderate magnitude, and jointly these factors may give valuable information for predicting NCFE score. There were some inter-correlations, e.g. between upper secondary/high school grades and average examination attempts needed to pass, but in a multivariate analysis both upper secondary/high school grades and average examination attempts needed to pass remained significant. Furthermore, the variance inflation factors were low, which indicates that there were no problems with multicollinearity. Thus, each of these factors contains information related to NFCE which is not explained by the other factor. To investigate which factors that could contribute with valuable information in a model, and if that model could predict NCFE score with a useful precision, is an important continuation of this study, and results from such research will be presented in a forthcoming article.
Implications for educators
Results from studies like this one may be used for organisational purposes, e.g. for planning and resource management. For instance, resources for extra examination could be allocated for some courses. For faculty, results of this kind, together with our sources of information and practical experience from running the programme, may contribute to the evolution of the nursing education programme and pedagogical discussions.
In this study it is clear, in terms of examination attempts needed, that there is a difference between medical and nursing science courses. Medical science courses are generally more demanding for students. In a report from the Swedish National Agency for Higher Education (), both students and educators speak of the programme’s varying demand levels between medical and nursing science courses, in terms of both work required and intellectual challenge. As teachers, we have experience of nursing students describing medical science courses as being more abstract, demanding and time consuming.
However, the clear differences in terms of challenges between the medical science and nursing science subjects indicate the relative importance of the nursing and medical science subjects in terms of promoting the nursing education programme’s completion rate. This difference may be due to students lacking the necessary problem-solving abilities and medical knowledge, contributing to a shortfall in nursing knowledge and understanding. Another explanation may be that the students are not provided an opportunity to understand how the presented knowledge should be processed and understood in relation to clinical situations.
Ordinarily, medical science courses take the form of lectures providing a mass of factual knowledge about the human body, illnesses, diagnoses and treatments in a short time. However, Lilja Andersson () and Benner et al. () indicate that the actual learning effect of such teaching is often relatively modest. For the student, lecture form teaching can lead to overload and fragmentation (Benner et al. ) and does not contribute to the deep understanding required for true learning (Ramsden ), as new knowledge needs to be processed, analysed and practiced to have a lasting effect. Interest for and deep understanding of lecture content would be promoted were students to feel that the content is applicable (transfer of knowledge) and meaningful in the context of the programme’s clinical practice periods (Marton and Booth ). Furthermore, other factors may influence how students absorb and develop the knowledge provided within the programme, such as intellect, study habits, work effort required and motivation (Marton and Booth ). Benner et al. () claim that the most effective teaching is achieved “through integrating all three professional apprenticeships, the knowledgebase, skilled know-how, and clinical reasoning and ethical components, in all teaching and learning settings” (pp. 80). Furthermore, they believe that the programme’s content should “[s]hift from a focus on covering decontextualized knowledge to an emphasis on teaching for sense of salience, situated cognition, and action in particular situations” (pp. 82). This means that a shift from teaching to learning and distributed knowledge is necessary. Students need to understand what is most important in the clinical situation (situated learning). Without such understanding students find it difficult to sort and prioritise the mass of knowledge received, and fail to understand how the knowledge can be used in clinical situations.
The result shows that a number of courses, e.g. Drug Calculation, have a significant correlation with the ability to pass the NCFE. Drug Calculation is crucial knowledge for every nurse for the sake of delivering exact volumes, in the correct manner, at the right time. For this reason, a barrier rule forces nurse students to suspend participation in further courses until the Drug Calculation courses have been passed. New NCFE regulations will demand 100% correct answers, thus making drug calculation even more important for completing the nursing education programme in future. This confirms the special importance for students of focusing on drug calculation in the nursing education programme in order to achieve their nurse degree and to increase the programme’s completion rate (NMC ). Wright () and Hunter Revell et al. () show that the programme’s content must allow nurse students to develop their drug calculation abilities in the context of clinical practice. Consequently, these finding underline the importance of having educators with advanced pedagogical skills and experience in order to meet the students’ need for support.
An important task for educators is to balance, integrate and optimise courses in both nursing and medical science in order to accomplish a holistic competence. One way to achieve this may be to focus on the strengths of the subjects’ approaches and explore how they can benefit from each other. Medical science course lectures should integrate more practical process-oriented learning and nursing science courses should integrate more theoretical knowledge applicable in the context of clinical practice periods.
This task is a challenge for nurse educators and calls for an approach in which theoretical knowledge and professional values are integrated with practical knowledge and clinical competence, thus providing an example of Work Integrated Learning (WIL). WIL is both a way to organise vocational education and a strategy to give it specific content (Patrick et al. ). WIL can serve as a pedagogical design to strengthen the nurse students’ progress towards understanding the professional skills (Jonsson et al. ).
The study covered the nursing and medical science examination results of 286 students within the framework of the nursing education programme at a Swedish university. Transferability of the study’s results and conclusions may be limited by the study population’s size and/or by the fact that all data came from a single university. The limited sample size may have affected the power, i.e. increased the risk of type-II error in some of the comparisons. For instance, there were not that many male students, which gives low power to analyse in terms of gender.
We conclude that grades in upper secondary/high school are related to performance in courses and results at the National Clinical Final Examination. A student with higher grades is more likely to complete courses with fewer examination attempts needed, to complete the educational programme and to pass the NCFE. Disregarding high school grades, the number of examination attempts for courses in general, and for some courses in particular, are related to performance on the NCFE. We also found that medical science courses demanded substantially more attempts to pass examinations than nursing science courses. These findings indicate pedagogical challenges for educators.
The authors thank Patrick Reis for his valuable editing, translation and proofreading assistance for this article.
Source of funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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