Date received: 22/07/2021 / Date reviewed: 07/10/2021 / Date accepted: 10/11/2021

ESTUDIO SOBRE EL ANÁLISIS DE LAS ESTRATEGIAS EMPLEADAS POR LA FACULTAD DE ENFERMERÍA PARA CUMPLIR CON LA RETENCIÓN DE LOS ESTUDIANTES DEL PROGRAMA DE ENFERMERÍA

Introduction

The World Health Organization (WHO, 2020) states that there is currently a growing need for quality information on human resources in health systems to improve decision-making and policies at the national and international levels. Eighty-seven percent of nursing professionals are concentrated in three countries in the Americas: Brazil, Canada, and the United States, which are home to 57% of the region's total population; that is, 80 nurses per 10,000 inhabitants in these countries, which contrasts sharply with the less than 10 nursing professionals per 10,000 inhabitants in Haiti, Bolivia, and the Dominican Republic (WHO, 2020). Another relevant fact according to WHO is that 3% of the nursing workforce is 55 years of age or older and is expected to retire in the next 10 years. Finally, the WHO also indicated that, in terms of the nursing profession, by 2030, countries will have to increase the total number of nursing graduates by an average of 8% per year and improve their employment and retention options for these health personnel. Moreover, educators play an important role with students, the educational institution to which they belong to, society, the future of the country, adjacent regions, both nationally and globally, and student retention. Through education, professional formations emerge that contribute to manage, remedy, and solve the needs that arise daily in our environment, in the country, and in the situations faced by the human being. The Manual on Monitoring and Evaluation of Human Resources for Health (Dal Poz, 2009) states that it is estimated that the world lacks over 2.3 million doctors, nurses, midwives, and more than 4 million health workers in general. WHO (2020) states that the Americas are home to 30% of the world's nurses, or about 8.4 million, 87% of whom are women. This concentration of nursing professionals is observed in only three countries that are home to 57% of this population.

The SARS-COV-2 pandemic made visible the fundamental role that nurses and other health professionals play in protecting people's health and saving lives. For this reason, it is important to understand and analyze the strategies that are employed by the nursing faculty to retain their students so that they become future professionals and contribute to the labor demand that exists in the world and especially in the Caribbean.

Public and private institutions offering professional studies in Puerto Rico are facing challenges in meeting the demand to maintain their enrollment numbers until students complete their professional careers. As described by Munizaga et al, (2018) the phenomenon of dropout and the retention needs of their students by professional schools within the Latin American and Caribbean region entails important social and economic repercussions, both for students, as well as for society as a whole. Attrition is a problem experienced by universities worldwide, not only in Latin America (Nuñez, 2020). In recent years, the issue of retention of enrolled students has become of vital importance in university education systems worldwide, mainly in the United States. Retention refers to the strategies that are employed by the institution to convince the student to remain in the institution. Attrition, on the other hand, is the action of abandoning the educational career. This phenomenon of student retention has continuously been the subject of study due to the negative repercussions it implies because, although it occurs in the educational sector, it affects the social and economic development of nations and influences the individual's ability to give in to a job, a home, and a decent lifestyle (Velázquez and González, 2017). In Puerto Rico, very little research has been conducted on the strategies that faculties use to retain their students throughout the professional path in which they enroll. Evidence indicates that student retention is negatively affected by lag factors; failure and absenteeism that would be considered very complex factors (Velázquez and González, 2017). Students are the customers of the institutions, so everything possible must be done to retain them, and it is not a job that will have to be done in isolation by the university but includes training teachers on the subject (Haverila and McLaughlin, 2020). To address the gap that exists in Puerto Rico and to collect data from the nursing faculty, this qualitative research was conducted on the retention strategies used by the nursing faculty to retain students in their courses.

Research Questions

The research questions were: What educational strategies do faculty use to retain their students? What strategies are currently helping faculty to retain their students through the completion of their coursework and selected educational program? and What strategies have worked for other nursing faculty to retain their students in their coursework?

Method

This study is qualitative with a hermeneutic phenomenological research approach which emphasized in this study the lived experience of the faculty participants of this study regarding the best strategies to retain their students until the end of their course. The topic of retention was guided through open interviews so that they could open up and share their feelings and experiences in order to contribute to other nurse educators. This approach allowed us to approach the knowledge, meanings, similarities, and understanding about the experience shared through the participants about retention strategies. Within the field of nursing, hermeneutic phenomenology is presented as a great attraction since it favors understanding the phenomenon under study and understanding the experiences of nursing practitioners from various educational institutions, selecting or seeking strategies to combat the problem of retention of nursing students in their courses. The components provided through this approach were that the participants provided tools for a better understanding and contribution on the meaning of each of these participants on the subject. They also contributed with strategies that have been effective in contributing to the preparation of excellence of future nursing professionals who will eventually revalidate and execute various skills or competencies, with diverse human beings in various stages and health conditions.

The sample consisted of 12 physicians working in public and private systems in various nursing programs in Puerto Rico. The selected participants met the following inclusion criteria: (1) three years of experience or more in the educational area, (2) with Master's or Doctorate degrees in Nursing Sciences, (3) offering courses in nursing programs, and (4) who agreed to be interviewed and that the interview was audiotaped. No practitioners with one year of work experience and who were not professional nurses participated.

The semi-structured interview guide was designed by the researcher based on the literature review. These questions were validated by a panel of five experts on the topic of retention, education, membership, enrollment, students, and faculty. These experts work in an educational institution as educators and hold administrative leadership positions during their experience. They were asked to evaluate each question to verify if they met the clarity of the research problem, wording, or offered recommendations that would help in the reliability of the study guide. A second validation of the interview guide was performed with two other professional practitioners in the area of nursing education with more than 3 years of experience. (Table 1).

Table 1

Interview Guide

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Part I: Interview on sociodemographic profile of study participants

1. Gender:
2. Age:
3. Nationality:
4. Experience:
   1. How many years have you been practicing as a nursing professional in structured and unstructured settings, not including education?
   2. How many years have you been working in the educational role as a practitioner in the existing nursing programs on the Island?
5. Geographical location of work area:
   1. In which zone of the Island do you work (north, south, east, or west)? If you work in more than one zone, please specify the zones you work in)
6. Academic Preparation:
   1. Mention your current academic preparation. If you have other information relevant to your academic preparation, please share it
7. Employment:
   1. Are you currently employed full time or part time?
   2. You are currently working as a faculty member in a private or public university. If you work in both systems, please specify

Part II: Question Guide

1. What is your understanding of the term student retention?
2. What questions do you have regarding student retention?
3. Letting ourselves be carried away by percentages or by the parameters: majority, minority, half, or none
   1. What number or what approximate percentage of students do you understand they retain the courses you taught or currently teach? Why?
   2. What has affected you in maintaining retention?
   3. What helps you maintain retention in your courses?
4. What strategies do you use most to retain your Nursing Program students?
   1. Why do you understand that you must use these strategies to retain your students?
   2. Of all the educational strategies you know or use in the classroom, which do you think is the most effective? Why?
   3. What do you understand to be the most effective strategy for retaining students in the Nursing Program?
5. What level of importance do you place on student retention?
6. What other factors at the institutional level do you understand affect or help student retention to degree completion?
7. Why do you understand that educators in the Nursing Profession find it difficult to retain students in their various courses?
8. In what semester or in what year do you understand that if we do not add retention efforts and strategies to retain students we may lose the student from the Nursing Program?
9. What benefits does student retention bring to you and the educational institution you work for?
10. How does student retention affect you as an educator? - If it affects you, if not, we move on to the next question.
11. How do you feel about student retention?
12. Why do you understand that educators must have good student retention?
13. What are the consequences for you as an educator of not retaining your students in the courses you teach?
14. What do you understand to be the best strategy you have used to retain nursing students in your courses until the end of their professional careers? And why do you consider it to be the best strategy, based on your educational experience?

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Procedure

This study was approved by the UNINI International Institution Ethics Committee panel. After advertising the research study on various educational institutions and social media platforms, such as Facebook and Instagram, several practitioners contacted the researcher to participate. Those who met the inclusion criteria were explained what the study consisted of and what was expected of them and were asked to sign the informed consent form. Then, an appointment for the interview was arranged by mutual agreement in a private place in the offices provided by the educational institutions or in private rooms in the libraries of the educational institutions. It was explained to them to use a pseudonym to protect their identity and privacy. The participants did not receive any incentive for their participation in this study. The study lasted approximately one year.

Qualitative research seeks to explore in order to obtain in-depth knowledge of a phenomenon or problem by obtaining subjective data shared by the participants; therefore, data analysis does not involve the use of programs or statistics. The Carrying Out Qualitative method was used for the analysis process of this study. First, to maintain the rigor of the approach, the interviews were listened to and transcribed word for word. Second, themes were identified that reflected the amount of data common to the participants. This step facilitated the coding of the data. All participant recordings were erased at the end of the study.

Results

Sociodemographic Characteristics

Twelve faculty members participated, including nine women and three men from various educational institutions. Sociodemographic data were requested including gender, age, length of time as an educator and nurse, place of birth, area of work, academic preparation, and whether the faculty was full or part-time. The majority of the sample ranged from 21-60 years and consisted mostly of faculty between the ages of 41 and 50 years (Table 2).

Table 2

Sex of participants

Age Range	Sample of participants
20 - 30	1
31 - 40	3
41 - 50	6
51 - 60	2
60 o más	0

Figure 1. Seniority as a professional

Since the questions were semi-structured with open-ended questions, an analysis was made of the answers given by the participants, as shown in (Table 3).

Table 3

Results of the interview application

ITEM	INTERVIEW RESULTS
Item 1	Most of the participants were able to define the concept of retention correctly or close to what is reported in the documentary part of the study. On the other hand, they expressed diverse knowledge and definitions about student retention. A female participant in the study verbalized, "Retention is a strategy that the professor creates according to the diversity of students we have in a course, to prevent the student from dropping out of the course, or abandoning their studies as a nurse." Female participant of the study verbalized, "To ensure that no matter how difficult it is for the student in the course, he/she stays, because he/she can count on me as a professional, and I will look for strategies so that he/she stays in the course and shows interest until the end, without wanting to leave."
Item 2	Most of the participants did not demonstrate "having doubts about student retention", since "most of them are currently working in their institutional places with retention by ordinance and priority in their various jobs as nursing faculty." A female participant of the study stated, "I have no doubts, but if it is a complex situation, I go to the person designated in retention for guidance."
Item 3	Using the terms of comparison with the indicative scale of "majority, minority, half, or none," they will express themselves as to how many students they retain in the courses they offer. Participants expressed that they "retain the majority of their students in their courses." A female participant in the study verbalized,"My retention was very high, only one or two of them did not finish. So, I manage to retain most of them".
Item 4	For the terms of the scale (majority, minority, half, or none) most of the participants opted to "express themselves in percentages of retention per course" offered at the end of the semester, trimester, or bimester depending on the study option offered by the educational institution they work for.
Item 5	The majority of the nursing faculty participating in this study use various strategies to retain their students, such as female participant in the verbalized study: "The first day of class I interview them, I meet them, I see their needs, I give them a pre-test, either verbal or written to know where they are at in order to go from the lowest level of learning to achieve the level of analysis and learning that I want to have in my classroom to meet the objectives of the course." “The first thing I do on the first day is to observe the group, I go to each one asking them key questions, such as if they work, where they live, who brings them to the university, if they have a family member who is a nurse, why they want to be nurses, among others. Then I leave them open that if they want to tell me something else in private they can come at the end of the class, I give them my cell phone number for any emergency, I make the classes interactive, depending on each group, I have younger groups and with laghter I have other more adults or with some kind of experience already in health. Something that attracts them a lot is that I tell them stories of things that happened to me or if not, I make up situations that could happen in the hospital and I pretend that it was me as a nurse that happened to me... from there I ask them and if it had been you, what would you do, and I raise their level of analysis and relaxation in the course.”
Item 6	Regarding the importance of student retention all participants indicated that they expose: Male study participant verbalized: "that their job or contract renewal depends on the retention of their students." Regarding student retention they expressed,"it is a fundamental criterion of their evaluation by their employers for the renewal of their contract." (Female study participant).
Item 7	The participating faculty expressed "that most go through various difficulties in retaining their students due to different factors faced by students in the Nursing Program." Among these they mentioned: A female participant of the study verbalized "that the student is often not motivated and is overwhelmed with many questions and too long works without measuring the capacity and knowledge of the levels of difficulty of each course". Sometimes not everyone has the intellectual capacity for this profession, they need to be humanistic and understand the long working days that await them. If a student identifies that they cannot handle the content or simply are not good at the science, mathematics, and humanism involved in this profession, they should be identified early on and directed to other study options. Nursing is not for everyone and that makes students to have and lose them after a clinical practice for fundamentals that change diapers, bathe, and cure ulcers. A great part of them cannot carry out these tasks because they should not be finishing a nursing career. Male participant verbalized, "Because sometimes our work is not respected, there is a bureaucracy in the institutions that regulate or regulate us and that makes it difficult to achieve. No one is supposed to change the grade given by the teacher to a student and it bothers me when someone comes with more position of us to ask because I take away points in spelling, content, and other areas that that is not what is going to be performed in the hospital, they do not realize that education involves other areas that are not giving medication and a complete of a whole. I understand that academic freedom must be present and no one should be able to control grading and evaluation decisions unless there are pre-existing situations with the teacher or the student, many times it is the student who thinks he had all A's in school and in the university as well, the format changes, the objectives, and styles."
Item 8	Most of the participants emphasized that "any time you can lose a student." They agreed that the biggest factor is "lack of motivation during their first semester or their first classes." Other participants expressed"that a student can be lost in the summer semester since the modality usually offers in one semester or in two months everything that is offered in one semester." A female participant in the study verbalized, "Summer is the busy season with little time for learning. Most students opt to drop out in my opinion and analysis in all these years of teaching. It is difficult to tell a student that what was offered in 18 weeks in one semester they will have in 18 straight weeks or even in 9 straight weeks every day."
Item 9	Most of the participants agreed that the "greater the retention of students, the more financial support institutions are provided to improve their infrastructure, payroll, technology, purchase of books and other supplies." The more students, the participants indicated, "the more opportunities the educational institution will be able to create to keep its employees employed, acquire new resources to offer better strategies, more training to faculty and staff, and other members of the institution."
Item 10	The majority of the study participants answered that student retention does not affect them. While the minority expressed that sometimes the institution demands a retention percentage per educational program and "it is a little frustrating" because many times "they do not manage to retain students until the end of the course." They expressed that there are several situations that they express with some courses offered to retain their students, but they "are not really affected by whether they finish or not, depending on whether the educational institution is private or public." Female participant verbalized, “It does not affect me, but in the clinical areas it is difficult to maintain retention due to absences or poor mastery of skills".. "If they don't meet the hours and standards, I can't retain them because they are recommended to withdraw from the enrolled course or repeat the course. It is not fair to pass a student without the skills and objectives of the course."
Item 11	Most of the participants in the study expressed that student retention often becomes "an obligation and ceases to be a privilege for a student who really needs to be retained in the institution" because of a situation that merits being retained. The key word of the majority of the participants in the study was “"that the institution takes away the authority of the decision to retain or not the student", ", which many times they expressed that the institution requires them to retain "the student who really does not have the capacity or does not deserve to stay to finish the course due to various non-compliances". The minority stated that it is a new method, "that helps them to keep their students but that they urgently need to be trained on retention, offered aids, strategies and workshops to be able to meet the demands of many of the educational institutions."
Item 12	Most of the participants in the study stated that having good student retention is important and beneficial for educational institutions. Most of them express that in some way they are categorized in their institution "as successful or good teachers", "provide them with pride," motivate their students, and contributed to their students' success. The minority on the other hand state that "having good student retention helps them to have a contract renewal or the difficulties that the course they are offering brings."
Item 13	The consequences as answered by the majority of faculty is that many "educational institutions penalize them for not retaining a number of students in their courses," while the minority stated that not retaining their students"makes their program not promoted" or "literally not marketed," "does not reach the numbers of students needed in the program's enrollment," and "will not help their program prove in the work field that they are good." Among the penalties participants mentioned for not retaining their students were "not renewing their contracts," "no recommendations as faculty who prove to retain their students," "considered them inflexible among others."
Item 14	The faculty participants mostly expressed that the best strategy "is communication," "getting to know the student," "interviewing the student," and "getting to know the student's needs." Also, most agreed that bringing their experiences as nursing professionals either in a hospital or any other nursing setting to their classes helped them to broaden the analysis," "to feel that the student could better understand the situation or disease they are discussing in class." Bringing experiences helps them greatly "to motivate the student" so that they can remember it in their exam and clinical area.

Discussion

Given the magnitude of the phenomenon of student retention in P.R., many educational institutions have been affected and more so with the changes triggered by the Pandemic, which led many institutions to acquire new ways of offering their courses. Many institutions reported in the different media of the country that they had to take measures to reduce working hours, dismiss employees, and close departments, among other aspects due to the low enrollment and retention of their students until the end of their courses or professional careers. In terms of the results obtained in this study, most of the participating faculty were able to clearly articulate what student retention means to them.

Student retention for most of the participants in the study was a type of strategy, which they use according to their group or students to keep them until the end of the course or career. This definition is consistent with what is described in the literature on this concept and involves the strategies that are employed by the institution to convince the student to remain in the institution and achieve the completion of their professional goals. The faculty participating in the study shared various strategies used to retain students in their courses in which most of them agreed on the importance of getting to know their students in order to identify their needs; group observation was another strategy presented by most of the participants in this study. Likewise, the most used strategy to keep their students encouraged in their courses was the implementation of sharing their experiences and situations that happened to them through their various engagements as nurses in different structured or unstructured scenarios.

Using the skills lab more frequently helped them to keep their students motivated to continue learning and feel closer to the goal of finishing their professional careers. Within this study, as a researcher, I was very impressed by the part of the study where several physicians expressed that in some of their jobs, the renewal of their contract depends on their retention. This is an alarming fact because we do not always have students who meet all the competencies, skills, and theoretical content among other factors to achieve their goal of finishing their careers. We must be aware that we will not always have students who can finish their course with favorable grades, but as physicians we must have the interest and tools to provide an excellent education in order to graduate nurses with the knowledge, skills, and competencies required by the regulations of the profession. The faculty should be aware and have a good planning of the lessons to offer to the students according to the participants of the study as diverse strategies or methods to evaluate such as diversity in the exams as pairing, choose, mention, questions maintain a variation and not be very repetitive since we have diversity in the learning of the students. We must be strategic and use these diverse strategies in order to retain students more effectively without affecting the quality of instruction.

During the study, it was possible to identify, through some of the faculty members participating in the study, the institutional demands that they expressed through this study to be able to comply with the retention of their students, which many of them understood were not fair and affected the quality of teaching or the commitment of the students with the decision to study and obtain the competencies required by the study curriculum. On the other hand, the lack or need faced by the physicians participating in the study in terms of resources at the educational level such as workshops, facilities, personnel, among others, to work the situation of retention in their jobs in a more efficient way was studied. As a result of this study, it is understood that even the faculty needs more support from the institution to be able to put into practice the various strategies that have been identified as effective in retaining students until the end of their professional studies.

Strengths and limitations

As in most research work there is a great variety, situations and diversities that make the limitations of the study that was investigated. For this work was no exception, it is worth noting that in this study I can conclude that within its limitations it moves me to investigate more about the problem because at the same time I emphasize that not only the retention of students lies in only retention strategies to retain students to finish their course if not this is a line part of the problem, but not the complete solution to the problem of student retention. Educational strategies will help faculty to improve their strategies and organize policies, protocols, or policies and combine them with content but not to achieve 100% student retention. Educational strategies to retain students play an important role in student retention, but they are not the only important element in allowing a student to remain at the institution or in their program of choice.

Among the limitations was the diversity of academic levels offered by the physicians participating in the study. Currently, nursing is offered in Puerto Rico as practical, associate, baccalaureate, master's, and doctoral degrees. By having participants offering different courses, the strategies used to retain their students until completion were diverse, although some were repetitive and of vital importance at the time of retaining students. Another limitation of this study in the same line that I can mention in this study was the academic level they teach, also teachers who offer several levels at the same time should not participate. Since they fail to identify or recreate exactly the scene if it was a good strategy or not according to the level of study offered to the student. For a next study I would focus only on a specific grade and not on all the existing ones. I can consider as a limitation of the study the faculty's ability to generalize the situation of retention, having samples of public and private sector faculty, having faculty that offer courses in different institutions for being lecturer or part-time faculty, and having regular faculty, i.e., full time.

Another limitation of this study was whether the faculty participating in the study worked for the private and public sector or public only or private only. Working in the public or private sector makes a big difference in how the strategies, efforts, goals of the educational institution are worked out and how the situations of the institution, the student, and the faculty are handled. In a next study in one of the exclusion criteria I would select faculty from only one sector of employment, or I would conduct a study comparing the strategies used by a professor in the private system versus the one in the public system. On a future occasion, I would carry out a comparison of the public and private systems since the requirements for these are different. Another limitation identified in this study is whether the teacher was full-time or part-time, as well as whether he/she had two jobs in different places related to education. As a limitation of the study is that the exclusion criteria were very open. On a next occasion I would make them more closed to better analyze the problem and the phenomenon of retention of a specific area since it was comprehensive of the offerings of the nursing faculty, and I would have liked to be more specific or limited. I understand that these details should be taken into consideration when doing any other study that has to do with strategies to retain students. Since as a researcher I was open-minded in the selection of participants, the requirements to participate in this research study should have been more limited. In conclusion, limiting the requirements for participation could help me to better analyze, study, compare, and develop my research study in order to contribute more effectively, accurately, and redundantly to student retention strategies without affecting the quality of nursing education at a specific level of study.

Conclusions

The findings compiled in this study reflect that nursing faculty are willing to retain their students, use a variety of strategies, and believe faithfully in getting to know their students before they begin working on any strategies to achieve retention. Getting to know their student to determine their strengths and weaknesses is one of the most commonly used retention strategies by the study participants. The strategy most used by the study participants was getting to know the student to work on their needs. This has helped the participants of the study to achieve retention in their courses has been of great help to them as they verbalized through the interview conducted to learn more about what is the best strategy for student retention in nursing programs. These participants give a lot of positive reinforcement using the experiences of their professional area as nurses, according to what they said. These experiences or clinical situations that they experienced on a daily basis in their past work scenarios greatly help the student, according to what they verbalized, since it motivates them, broadens their knowledge, they work on a situation, and through these they can apply the content to make a complete learning process and not a passing one.

Schools require greater connection with students to motivate and captivate them to learn since they are digital natives, i.e., they are born already immersed in the era of digitalization. Teacher updating in communication and information technologies is a dual action task that should be coordinated by school directors, in addition to being sought by the teachers themselves as part of the updating of their knowledge. The introduction of recreational activities, demonstrative practices, among others, can make the difference between the student before deciding to drop out of the nursing career.

It is important that these students who apply these retention strategies and successfully complete their professional career will be revalidating to practice their professional career as nurses. These situations of real or hypothetical clinical cases that they share with their students is a very good retention strategy, according to what they said, since it will help them complete the challenge of successfully revalidating. It was also found through this study that some of the physicians participating in this research study agree that retention is an essential part of the institution's improvements, but their contract renewal assigned course load that they could offer in the future could be affected if they do not retain the percentage established in their courses in the educational institution in which they work.

The quality of teaching should not be affected by any situation of retaining students. It is understood that each practitioner must exercise his role and maintain his commitment to impact in substantial and complete knowledge to each of his students enrolled in his course. Nursing professionals will be the ones in charge of the health of the people, the country, and the world. In conclusion, through this chapter of this research study we can affirm that the practitioner despite knowing the term retention and having a good retention rate in their courses needs more knowledge to manage strategies and situations of the most complicated students in the classroom. In this study, according to the findings the faculty, showed that they need to learn to manage strategies for students who are affected most of the time with situations that do not allow them to continue attending full time to their courses or finish with the classroom content, demonstrate the responsibility and competencies required in a work environment or the total fulfillment of the objectives.

According to these results, we validate the need for nursing professionals to apply strategies to educational workshops, evaluate the needs they face with students, as well as to know that there are institutions that require them to retain students without having sufficient criteria to remain until the end of the course.

This research will help faculty, administrators, and lecturers who work every day to improve retention in their educational institutions. It can be finally concluded that retention does not fall on the practitioner as a whole if there are no other factors that fall on the student, the campus, the technology, and the environment that affect the student's permanence until the end of the course.

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Haverila, M., Haverila, K., & McLaughlin, C. (2020). Variables Affecting the Retention Intentions of Students in Higher Education Institutions: A Comparison Between. Journals of International Students, 10(2). https://doi.org/10.32674/jis.v10i2.1849