Enhancing Nursing Student Success: A Critical Realist Framework of Modifiable Factors

There is a range of literature examining the predictors of academic success in nursing including age, entrance qualifi cation and background. However, these are factors that cannot be changed once a student is on a programme of study. However, there is currently little or no literature that focuses only on the modifi able behaviors and environmental factors in achieving good academic success. This project aimed to explore the modifi able factors that may infl uence academic performance and develop a framework to guide students and academic staff. A critical realist ‘intensive’ approach employing qualitative methods was used with pre-registration 3rd year nursing students as participants. Unstructured interviews with use of academic grade documents as a point of reference. Thematic framework analysis enabled comparison on a case-by-case basis. Eight modifi able student themes were identifi ed: time management, understanding of learning outcomes, focus on the topic and its role in the wider programme, utilization of academic team, peer support, using feedback, life management, and management of stress factors. Four themes for academic staff were found under the headings: encourage, enable, empower and ennoble. The framework presented provides focus on the factors that can be changed and infl uenced in order to achieve success. This framework may be used by staff and students to develop guidance documents or in design of teaching and assessment. Research Article Enhancing Nursing Student Success: A Critical Realist Framework of Modifi able Factors Gemma Sinead Ryan* Health (Nursing), University of Derby Online Learning, Derby, United Kingdom Dates: Received: 05 April, 2016; Accepted: 02 December, 2016; Published: 05 December, 2016 *Corresponding author: Gemma Sinead Ryan, Senior Lecturer in Health (Nursing), MSc; PG, Cert Adv Health Prac; BSc (Hons); Dip HE Adult Nursing RNT; QTLS University of Derby Online Learning, UDOL, Enterprise Centre, Bridge Street, Derby DE13LA UK. E-mail: g.ryan@derby.ac.uk


Performance indicators & the importance of modifi able factors in academic success
Understanding the reasons for success and failure in nursing programmes has been a topic of investigation for many years. Preventing academic failure is a core focus of Higher Education Institutions. Factors such as entrance qualifi cation, age, gender, and ethnicity and work commitments have been linked with academic success or failure in both nursing and other degree programmes [1][2][3][4][5][6]. However, there is contradictory evidence about the infl uence of some of these factors and the defi nition of 'success' or 'failure' is also inconsistent [7]. This makes it diffi cult to draw comparisons but seems to place signifi cant focus on factors that educators, students and HEIs have little control over once students are on the programme. For example, gender has been linked with academic performance in nursing but there is nothing educators can do to change the age of a student once they have entered a programme of study.
Hence, this research project sought to focus on those factors [modifi able] that can be improved, changed or enhanced (e.g. study skills strategies).
It is evident that the majority of the available literature focuses on indicating performance with a view to amend entry criteria or early identifi cation of those who may be 'at risk' and/or factors that cannot be changed easily once a student is on a programme of study e.g. age, entrance qualifi cations and ethnicity. There is literature that discusses possible behaviors and characteristics that educators may facilitate to enhance performance. However, no literature has been found that examines the actions and behaviors of those students who are successful in achieving good or excellent academic grades.

Review of the Literature
Frietas & Leonard [8], conducted a survey of 190 nursing students needs based on Maslow's Hierarchy. While the survey was limited to Likert responses this particular piece of evidence was unique in that it considered the ability of students to meet their learning needs and suggested possible methods by which Citation: Girisgen  this could be achieved. Pitt et al. [9], considered the personality traits of nursing students and how these may impact on academic performance through a cross sectional study using a validated personal qualities assessment. However, while the fi ndings may be informative it is argued that changing personal qualities of students would prove to be complex and unrealistic.
Pitt et al. [10], further suggested that critical thinking skills impact on student academic performance through the use of a validated health sciences reasoning tool. Again, this supports the development of critical thinking skills across the academic programme but the conclusion placed focus on assessing critical thinking upon entry rather than the methods by which to facilitate these skills.
Ofori & Charlton [1], developed a theoretical framework illustrating the factors impacting on academic performance and although this acknowledged some modifi able factors, the primary start point was age and entry qualifi cations. Factors that students and academic staff are unable to change once on a programme.
Conversely, Ali & Naylor [11] conducted a statistical analysis of academic records of 628 students in Pakistan, fi nding unexplained variance in a range of performance indicators, suggesting that there are wider infl uencing factors such as fi nancial issues. As a result they recommend the need for qualitative research with students who are 'successful' in order to examine the underlying mechanisms. It emphasised that one consistently accurate method of predicting performance for the purpose of recruitment and selection is unlikely to be possible.
Dante et al. [7], conducted a systematic review of literature relating to performance indicators and success. This confi rmed the complex nature of nursing student's academic performance, illustrating that infl uencing factors for one student may be very different for another. It is known that students who work, have family commitments and come from a range of backgrounds can still be academically successful despite what the evidence states. Furthermore, Urwin et al. [12], contests that there is little HEIs can do to attribute causation to academic success or failure, nor are they able to control such causes. Therefore, it is concluded that HEIs should develop policy that supports those behaviors and factors that are modifi able for the University and the student, enabling and empowering students to overcome the potential barriers [7]. The available literature has been unable to effectively address the methods by which HEIs and students can predict academic performance. Conversely, the focus on preventing failure [although important for attrition] seems to take a negative approach, particularly if identifying factors such as age and ethnicity that educators and students can take no action to change. It is contested here that HEIs and students should be empowered, enabled and encouraged to adopt behaviors that will help them to overcome the challenges faced and improve their academic performance.

Aims and Objectives
'What are the modifi able factors that explain why some nursing students are successful in achieving good or excellent grades?' This research aimed to explore the factors that determine 'good' academic performance with a view to explain the underlying behaviors and actions of students who achieve 'good' academic performance during their programme. Good academic performance is considered to be a 2:1 or 1 st degree.
1 illustrates the international comparisons for a 2:1 or 1 st degree in the United Kingdom. As a result it hoped to develop a framework for students and staff that can be implemented and evaluated.
The objectives were: • Employ a critical realist approach using qualitative, unstructured interviews with third year pre-registration nursing students • Critically analyses and compare determining factors, modifi able student behaviors and experiences using a thematic framework analysis • Develop a framework that will inform students and academic staff on the approaches to enhance academic success Bhaskar (1975) [13], Alternatively CR argues that there are mechanisms that exist beyond what we control within a closed experiment or an individual's perception of a situation. For example, gravity still exists whether a researcher is conducting research or not and it existed before humans were on Earth. Conversely, CR would argue that an interpretivist view that reality is based on human constructs of that reality only seeks to explore their perceptions of it rather than explain the underlying mechanisms that may explain it; society exists as a result of these mechanisms rather than constructed by those within it.

Critical realist (CR) approach
CR favours an intensive research design with in depth analysis of a focused number of cases [14]. The world is considered to be stratifi ed over three levels ( Figure 1) and such an approach enables the complexity of the underlying behaviors and actions of successful students to be observed (empirical), explored and explained (actual). This can then be considered alongside current research evidence and applied to the most 'likely' theoretical model refl ecting the 'real' domain.
This also acknowledges that 'reality' may change over time and that there are different possibilities in different situations.
Applying CR to this research process will enable a transferable model to be developed that is adaptable to range of situations in Citation: Girisgen  nurse education. As a result of the conclusions from published evidence the application of this approach seeks to provide a model to facilitate success rather than control the predictors of success [7,11,12]. CR has therefore been chosen here as it specifi cally seeks to explain and understand the possible infl uencing factors of behaviors rather than participants perceptions of them. It will also enable a focus on the factors that can be changed rather than the things that cannot.

Sample and recruitment
Participants were recruited from a convenience sample of two cohorts of pre-registration nursing students undertaking a programme of study in adult or mental health nursing in the College of Health & Social Care. A convenience sample was deemed to be appropriate given the resource available and that the programme is delivered over two geographic sites. The University is located in the East Midlands of England, UK and has two sites of programme delivery in the West and North of the region. The nursing student sample population had the following characteristics and are deemed to be typical of the student nurse population in England and similar demographics to those training in the USA and Australia [15][16][17] • Student in the fi nal 6 months of their programme of study • Had achieved a good or excellent grade for the fi nal two years of their study and likely to achieve a 2:1 or above (Table 1) • Pre-registration adult or mental health nursing • Willing to provide informed consent Students were recruited via two methods: 1. an email sent through the University system 2. face to face when they attended a taught session on campus They were provided with a participant information sheet and an expression of interest form. Following this a mutually acceptable interview date was arranged. Participants were given the opportunity to ask any questions and asked to sign an informed consent form. Interviews were undertaken in a private room on one of the University campuses.
Interviews were undertaken until data saturation was achieved. Given the current literature on similar topics was estimated that this would require between 5-10 participants [18].

Data collection
Open interview was chosen to enable students to recount their academic journey with the prompt of their current academic transcript. This meant that students were free to explore areas where they particularly excelled and begin to think about what may have been different or similar based on comparisons of performance in one module to the next.
Interview prompts were used to clarify meaning of responses or probe further into the underlying reasons 'why' they did or did not do something or 'why' they did or did not think something; similar to the 5 whys of root cause analysis [19,20]. This sought to identify the underlying causal factors that infl uenced behaviors and complements the CR approach. The researcher took notes during the interview in order to prompt later analysis but also to indicate where probing questions might be required without interrupting the participants account.
Interviews were digitally recorded and transcribed by an experienced member of University staff.

Data analysis
A fi ve stage framework analysis using the approach outlined Interview transcripts were read and re-read to identify initial codes and key themes. Firstly the student's actions and behaviors were addressed, followed by the University/

Ethical considerations and approvals
Ethical approval given by the College of Health and Social Care Research Ethics committee. Participants were allocated a unique participant number and all transcripts were read to ensure any identifi able data were removed to ensure anonymity.
All research documentation was kept in accordance with Data Protection Act (1998).

Rigour
The researcher was known to the students as a Senior Lecturer in the University where they studied, however the researcher was not involved in teaching or assessment of the students.
Clarifi cation questions were used during the interviews and noted during the interview process with a view to enhancing credibility of meaning and fi ndings. Along with this, the ideas generated from analysis were discussed with a student and member of staff, given that it was the researcher alone who analyzed and interpreted the data.
Transferability is often diffi cult to ascertain in a study such as this [23], however, the main goal of this CR study was to inform the development of a framework that may be adapted by others in other contexts. The very nature of CR acknowledges that reality and truth can never be fully known, and that it may change with time, context and location. Hence, the goal here was to develop a framework that acknowledges this principle.

Results
A total of 6 participants completed the open interview. Their mean age was 29.8 years with 2 male and 4 female participants, two from mental health nursing and four from adult. Given the sampling frame and typical UK population, this sample was deemed to be similar to the local and national average.
Interestingly, almost all of the participants expressed a lack of confi dence in their abilities and were repeatedly self-critical, suggesting that success is not necessarily linked to confi dence.
It was observed that all of the participants seemed to have high standards and made comments such as: "just want to scrape through…I want to do well" (participant 001) "D+ and I was heartbroken with it. Absolutely heartbroken" (participant 002) They had a genuine need to do well although their ideas about 'doing well' meant that some felt grades that would lead to a 2:1 degree (60-70) were: "I got 60 something…that annoyed me" (participant 004) "I got an A-on that one and in the second year I got 68…which both times I was reasonably disappointed with" (participant 003) Almost all participants discussed their background and journey that had led them into their degree programme. However, comments about personal motivations, age, upbringing and past experience was attributed to nonmodifi able factors and was not reported here (but is reported elsewhere in the literature).

Modifi able factors -student
A sample of the framework analysis undertaken can be seen in Table 2.
The overarching themes for student modifi able factors were:

Factor 1. Time management -assessment focused
Almost all of the students spoke of time management when approaching assessments in their programme, they also recognized that the programme and studying was more than a 9-5 job. Assignments were of particular focus for all participants. All participants made reference to starting work on assignments early on in a module and ensuring that they were completed well in advance of the deadline:  Conversely, students also felt that planning sections of the assignment and working on this for short and regular periods of time was the most effective and productive approach: "…I will set aside an hour most days" (participant 002) "I don't think well I've got 6 weeks, 7 weeks to do it…even if it's just 100 words I do a little bit more and the more I do the more I feel better about it…always take time away from it…don't ever spend longer than an hour at the computer without taking a break…it will just get muddled up" (participant 003) Students also felt that almost completing or completing the work with at least a few days prior to the deadline meant that they could leave it and return to it to tweak and fi nish off with a different perspective:

Factor 2. Understanding of the module and assessment
Participants discussed how they begin to understand the module purpose and the assessment process. They felt this was important in order to understand what the requirements would be to pass with higher grades. Finding and understanding the marking criteria, module content and learning outcomes prior to or very early on in the module was considered to be good

Factor 3. Focus on the topic and programme rather than just the assessment
Participants identifi ed the need to make effort to understand the context of the programme and career rather than just see things as a 'single' assessment. This was emphasised repeatedly through acknowledging the need for wider reading and research around a topic but also nursing practice throughout the programme to make this relevant to 'nursing' and learning rather than just the assignment. Conversely, participants did not focus solely on the transition between academic levels e.g. second year to third year and the 'critical analysis'. Although it was recognised that moving between levels caused anxiety for some students they approached their work in the same way. As they progressed through their course they increased the level of wider reading in academic journals and felt that this was a natural progression.
Furthermore, participants acknowledged the role of the course in their career pathway and lifelong learning rather than just 'training' and qualifi cation as the end goal:  Using the library to work in but also as a resource for research was also noted as important.

Factor 5. Peer support mechanisms
Peer support mechanisms were repeatedly referenced.
These were face to face and through social networking platforms; predominantly Facebook groups for specifi c cohorts.
Participants all acknowledged the important role their peers play in their support systems but also learning: These mechanisms have also shown to reduce anxiety related to simple pieces of information e.g. whether uniform was required for attendance at university. Facebook was also used to just feel part of a group and know that others were feeling the same way or to share ideas and get rapid feedback without being in the University.

Factor 6. Assessment feedback
All participants discussed the role of assessment feedback. This wasn't just seen as a single assessment but they felt it was important to take general comments from it to improve.

Modifi able factors -university/staff
Prestwood & Schumann (no date) outlines the Art of Leadership for motivating and creating the 'right' environment for change that encompasses: encouragement, empowerment, enablement and ennoblement. CR emphasises the need to consider the most likely and appropriate theories that may explain a situation [13]. As the transcripts were read and reread when analyzing the university/tutor behaviors it became apparent that this theory might be appropriate for application here. It is for the educator to facilitate a change in behaviors or outcome in order to promote success. To test this theory, codes were applied within the framework analysis and then attributed to the overarching themes in this model.
The common themes identifi ed can be viewed in Figure 2 Development of a framework A framework was developed that included: • Determinants of behaviors -personal and external • Factors and mechanisms as a result of these behaviors -behavioral and environmental • Desired outcomes presented as overarching themes The framework is illustrated in Table 3 The presentation of the framework in this format intends to enable addition or amendments to each section as more is learned about the students and context.

Discussion
Much of the literature discussed previously is focused on non-modifi able factors on performance such as age, ethnicity, route of entry and gender. While this may inform recruitment and retention or early intervention for [potential] academic diffi culties it is unlikely [and unfair] that academic teams will change recruitment methods to restrict entrance to a programme based on these factors. Therefore, identifi cation of modifi able behaviors and desired behaviors that might improve the chance of success [good honors degree] has been identifi ed within the framework proposed ( Table 2).
All participants in this study have reported time management in assessments (factor.1) as an important factor for their success. Similar fi ndings were reported in Ggweta [24], who directly attributed assessment preparedness and planned, timely study with academic success. In addition, support mechanisms and programme engagement have been identifi ed as valuable. Frietas & Leonard [8], also support this, suggesting that staff should have mechanisms in place to signpost students to appropriate support mechanisms, learning communities, study groups, associations and promotion of social learning.
The framework presented found that students should engage with the programme and support systems available (modifi able factor.4). This refl ects the work presented by Addus et al. [25], who found that students who seek support and feedback are more likely to achieve better grades. Conversely, this also informs actions required on the part of the University and academic staff. Support mechanisms provided at a school or college level were more likely to be used and show student improvement than those at university level. Ggweta [24], also found that radiography students who were able and willing to search for sources of literature and engaged with learning and reading outside of the classroom were more likely to be successful. This is also refl ected the framework proposed here and might suggest that academic staff could also provide some steer with regards to self-directed study. Further to this Zyl & Baauw [26], conducted a study in order to improve student success and found that an extended induction and orientation process specifi cally aimed at support mechanisms and academic success is valued by students and may improve success. To improve student confi dence in seeking support, staff should signpost encourage, enable and empower students to seek support and this is of particular relevance to those from black, minority and ethnic groups [1,2].
Attendance in the University has also been found to potentially enhance student success along with willingness to engage once there. McCarey et al. [27] and Salamonson et al. (2009) found that this was of value and this could indicate that academic staff should monitor and take action on attendance as early as possible and should explore methods by which to effectively monitor and take action on poor attendance.
Conversely, there is evidence to suggest that monitoring of student performance and attendance regularly and as a   [1,25]. In this study, participants saw the value in this 'overview' feedback and proposed that personal tutors may be best placed to do this. They also identifi ed that this would enable comparisons to be drawn, student strengths and general areas for development to be identifi ed.
Stress has been shown to be a factor that impacts on student performance, which has also been reported in this studies participants which has also been identifi ed Addus et al. [25] and other literature. Here, several participants reported using exercise, which was linked to improved academic success in Mansfi eld et al. [28].
Participants here reported the importance of understanding the module and its requirements in order to do well in assessments. Conversely, Ofori & Charlton [1], emphasized the need to ensure that assessments were of appropriate diffi culty for the academic level along with constructive and detailed feedback. Many of the participants here expressed a lack of confi dence and self-criticality in their performance. Improving student confi dence means an increased likelihood of securing employment; conversely confi dence has been linked to academic success [29]. Academic staff may consider the methods by which to encourage, enable, empower and ennoble students in order to facilitate the improvement of confi dence.

Limitations
This is a small and limited study with 6 participants.
However, this does favour the intensive research strategy suggested in critical realism [14], the overarching models and themes are transferable and able to be adapted based on individual situations and organizations in the absence of similar models being available. In order to strengthen the transferability of the model a longitudinal study across several sites may be required.
Participants were from White-British origin that may limit the interview fi ndings. However, the framework developed should be adaptable and added behaviors, actions and themes are possible as it is utilized in different contexts.

Conclusion and Recommendations
The factors that impact on student success are multiple and complex, behaviors and actions of both students and staff can help to improve this.
There are a wide range of modifi able factors that have been identifi ed that may infl uence the success of pre- in particular contexts and can be used fl exibly by students or staff. It is acknowledged that this framework is a basis in going forward and the list of modifi able factors is not exhaustive but a starting point for knowledge. The recommended use of this model may be as an assessment tool, prompting students and academic staff to refl ect on and consider how they may meet their student needs, along with the available research evidence that might indicate appropriate and best practice methods, relevant to their own context and need.