The crusade - a metaphorical explication of the journey made by mature female undergraduate nursing students

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Introduction

Changes in nurse education combined with changes in access to tertiary study have given rise to different student profiles in nursing. Globally, mature age students now account for over 50% of students enrolled in most university programs^1-5. While mature students undoubtedly bring many special qualities to their education, they frequently experience pressures such as lifestyle changes, largely because of altered financial status, managing family responsibilities and university commitments, working part-time and maintaining their relationships with partners and family members^6,7. The experience of transition is concerned with dealing with change, which requires individuals to engage in adaptable and flexible behaviours. Mature students are in a process of transition as they journey through their university degree. The transitional period is signified by various overlapping stages. This article describes a grounded theory study that examined the journey taken by mature undergraduate nursing students.

Little has been written specifically about mature students in undergraduate nursing programs; however, there is a wealth of literature concerning the recruitment and retention of mature students in tertiary education^8-10. Despite differences between academic programs, the issues that confront mature female students appear to be identical. The literature emphasises that mature students experience difficulty with isolation, time, guilt, family and partner problems, finances, transition, orientation to university and stress^11-13.

Many mature undergraduate nursing students are studying in order to change career, bringing to the learning environment valuable life skills and knowledge^14,15. Often these 'second career' students previously held well-paid positions in the workforce and the return to study potentially places severe limitations on the social and relationship aspects of their lives because of the financial constraints of becoming a student.

Workforce trends in Australia indicate rising numbers of women working, with increasing importance being placed on credentials¹⁶. Additionally, there is evidence in the literature that women returning to study continue to be responsible for parenting and household issues, while men do not always carry the same responsibilities^17-19. Ehrhardt²⁰ found that many women returning to study compensate by doing all household chores, while this was not found among males. Alternatively, mature aged men, while not undertaking the majority of household tasks, often work between classes to meet the financial needs of their family²¹.

Arguably, time management becomes the most significant survival tool for most mature students as they attempt to balance their roles and responsibilities. Arsky²² contends that finding the balance between family, study and employment is a continual challenge for mature students. Arsky's comments²² suggest that being a mature student and parent/homemaker/employee creates competing priorities, making the journey more onerous for these students than for school leavers. Indeed Bay¹⁵, in her study of 85 adult students in New York, found that time was the most significant issue for mature students. Other studies also identify a lack of time as being a considerable contributor to stress as mature students try to balance the varied role demands of mother, partner, student and worker²³. Carney-Crompton and Tan²⁴ found that an increase in time conflicts, roles and demands were associated with high levels of stress, anxiety and depression for mature female students. Consequently, the demands made of mature students mean they must be disciplined and manage their time effectively²⁵.

The grounded theory study described in this article provides educators with an understanding of the different stages in the mature age student's university journey and, more significantly, the factors that facilitate their management of various roles.

Aims

The aims of this the study were to explicate the journey that mature students navigate when undertaking an undergraduate nursing degree; identify relevant psycho-social issues for this cohort; and explore the factors that enable mature students to negotiate their undergraduate nursing degrees. The study was undertaken at two rural Australian university campuses, referred to as university A and university B. Although these university campuses were located in different states, the regional demography in relation to economy, industry and population were similar. The stimulus for exploring this issue was the increasing number of mature females enrolling in the undergraduate nursing program at university A, where one of the researchers worked.

Method

Participants

In total six participants were recruited from university A and four from university B. Participation was invited at university A by a notice on the student notice board that invited nursing students over 21 years of age who were interested in participating in a research study to complete a form and place it in a sealed box. Convenience sampling from this cohort against further criteria of gender, year of study and whether they were part-time or full-time attendees then occurred. Convenience sampling is commonly used in research as it provides an easy, fast and inexpensive method of obtaining participants.

At university B the opportunity to self-select was given to all undergraduate nursing students via an email sent by student services. The email invited students over 21 years of age who were interested in participating in a research study to contact the researcher by email, or to leave their names on a form at student services. Collaboration with the year coordinator resulted in identification of the best time and day to conduct the focus group and respondents to the email were invited to attend. In all, two focus groups were organised; however, the numbers of respondents who indicated they were planning to attend and the number of respondents who actually did attend were quite different.

One participant had previously attended university for 12 months before having children. Of the other participants, the highest academic achievement had been a TAFE certificate. Three participants had division 2 hospital-based qualifications. Of the remaining participants, none had any academic qualifications. All participants were in the second or third year of their baccalaureate program. Although it was unintentional, all participants were female. Of the six participants who were interviewed, four were married, one was a supporting parent and one had never married. Five of these participants had children. Of the focus group members, two were supporting parents and two were married. All focus group participants had children. Three of the 10 students were second level (division 2 or enrolled nurses) and were working in this capacity in acute care settings.

Participants had all attended clinical placements that were both rural and urban. Participants who were interviewed individually attended four two-week placements each year and two of these would be in the local area (a radius of 100 km from the university). Focus group members attended one placement a year in the city (200 km away) and the remainder were in the local region.

Initially the research project was introduced to all students at university A on the first day of their second year of study. At this time students were invited to participate and were told that a flyer would be placed on the notice board concerning the study. Recruited participants from university A were followed over the last 2 years of their university course and were interviewed twice during that time. One student from this cohort withdrew from the nursing course and the study. University B participants (focus group participants) were interviewed once at the end of their second year of study.

Study design

Participants from university A were interviewed using semi-structured interviewing techniques. The initial question put to participants was 'Tell me about being a mature student at university'. Participants from university B were recruited to participate in a focus group. The focus group involved encouraging participants to carry out four activities. Materials used for these activities were laminated statements and possible category titles. These materials were used to stimulate discussion and keep the discussion on track. The activities tested the emerging conceptualisations by asking students to first discuss the transition to university and the rites of passage they have traversed. They were then asked to match statements from university A interview transcripts with proposed transitional periods. The second and third activities involved asking participants if the names on the potential model were reflective of the components, and participants were required to match statements made by participants interviewed individually to the proposed components of the model. They were then asked to give a name to the model. Finally, participants were asked to discuss the issues they experienced and the coping strategies they used to manage these.

Interviews were conducted by a doctoral student. Data were tape-recorded and transcribed verbatim. Transcriptions and coding were scrutinised by two experienced researchers. Ethics clearance was obtained from the ethics committees at university A and university B.

The nursing programs at both universities were a mix of theory and clinical practice. The study was limited to nursing students due to the interest of the researchers and the reality that these were the largest cohort of students on each campus.

Data analysis

Data were analysed using constructivist grounded theory methods^26-28. Charmaz²⁶ who coined the term 'constructivist grounded theory' refers to the process of coding as being the first step in the grounded theory process. Therefore, coding was the building block of the grounded theory and involved the researcher classifying sections of data with a name that concurrently condensed and explained each piece of data²⁶. Coding was the analytical process that showed how data was selected, separated and sorted^26,27,29. Coding became the critical connection between data collection and the development of a constructed grounded theory; it was how sense was made of the data. Unquestionably, coding became the foundation of the constructed grounded theory while also guiding further data collection.

Using metaphor to conceptualise findings

In research, metaphor is used to help the researcher reduce data and thus assists with conceptualising and cognition. Metaphor, a figure of speech that is used to compare things, is increasingly used in nursing literature^30-33. Birks et al³¹ assert that the use of metaphor facilitates the exploration of reality. Kangas, Warren and Byrne³⁰ in their discussion on the use of metaphor in nursing research, state: '...metaphors do not add description, rather they add depth of meaning to the nature of phenomenon'. Metaphors, like other figures of speech, are used extensively in normal communication, often helping to illustrate a point from another perspective^32,34. Thus, metaphor is used to help gain an understanding of the data within the whole. In this study a substantive theory was generated using a crusade metaphor to explain how mature age undergraduate nursing students managed to navigate their way through university. This metaphor emerged after a student repeatedly referred to the way she 'soldiered on' when confronted with crisis during her university study. The researchers' reflected on this and began to realise that the various stages identified could be viewed as a soldier's journey. Looking at the data in this way created new meaning and interpretation.

Current literature pertaining to mature students concentrates on inter-role demand, role conflict and academic retention. Birks et al³¹, while discussing baccalaureate nursing students in East Malaysia, also describe the undertaking of a degree by these students as a journey with stages. This study identified the stages of the journey as setting sail, finding one's sea legs, all in the same boat and discovering the treasure. Although contextually different, similarities also exist because their findings indicated that participants were confronted by a number of challenges, including time management, conflicting priorities and role blurring.

Results and Discussion

Throughout the individual interviews and focus groups, participants spoke of their university study as being a 'journey' with a clearly defined beginning and end. Although only two participants actually articulated this as a journey, others spoke of 'before I started uni', 'when I started uni' and 'when I finished'. This journey became the core category and consisted of five phases: (i) initiating the crusade; (ii) engaging the force; (iii) retreating to a place of safety; (iv) soldiering on; and (v) the victory march.

Initiating the crusade

Participants in this study identified beginning to think about undertaking study and how they would manage their roles at least a year before actually enrolling. During this period participants decided on the course of study and began to make preparations to apply to the university. For some participants these preparations involved a pre-enrolment course to achieve the required entry skills. These pre-enrolment courses are often identified as 'entry into nursing' courses and provide students with a TAFE-level 'certificate 4' qualification. Students undertake units in anatomy and physiology, communication, basic mathematics, lifespan development and academic skills preparation. There is little in the literature that discusses this stage of preparing for university; however, this stage was critical to participants in this study being able to undertake their courses.

Participants spoke of the need to plan and organise their lives prior to commencing university. All the participants were women with roles that included being a parent, a partner, a primary caregiver and homemaker for their families. Similar to the soldier preparing to embark on a crusade, participants spoke of the need to organise their diverse responsibilities to allow them to attend university. Organising childcare and home responsibilities was critical for these participants. Having childcare organized was identified as the highest priority for, without this, returning to study was simply not achievable for these women.

I wondered what I would do with [my] 4 year old daughter, and went straight down to the little day care centre down there and got her in straight away. (Participant 2)

I was breastfeeding the baby [and] B was a toddler, but that would pretty much be the biggest concern that I had. Whether I was going to be able to juggle it because neither of my kids were at school. (Participant 5)

All the participants also worked in some capacity and so work times also needed to be negotiated prior to commencing. Only one of the participants did not work either as a carer or an assistant in nursing. This participant was also the only one not performing shift work. All the other participants worked after classes, most often afternoon shifts and at weekends. This clinically based work alleviated participants' anxiety on their initial clinical practice units in aged care facilities. However, they all felt that the acute care clinical practice required different skills and knowledge. Interestingly, the participant not employed in a nursing role was the only participant in the study to withdraw from her course during the study.

Although participants spoke of 'external units', limited units were available externally and most of their courses were on-campus. In rural areas there were limited facilities and resources for mature students in terms of child care, especially before- and after-school care. Thus, timetabling was a significant issue for all participants. Some of the participants lived in areas where there was no school bus and so they had to collect children from school. If lectures were after 15.00 hours they simply had to miss out so they could collect their children. A further consideration was the distance that many participants had to travel to get to university. A common thread running through all interviews was travel time, with the average distance traveled being 100 km each way. Focus group participant 1 lived so far from university B she had to relocate during the week and have friends care for her son. Each Friday after class she would drive 300 km home and return to the university campus late on Sunday night. While travel time was a major consideration, so was the financial cost of travel. Rising petrol prices meant that students were always keen to complete units by distance education. Although participants spoke of wanting distance education units, they also spoke of the support gained from attending classes, and felt a combination of the two modes was preferable to a purely distance education model.

Engaging the force

Once participants enrolled at university and attended their first classes they were confronted with a new set of rules. Furthermore participants stated that to manage their university study they needed to learn how to execute various new skills, such as computer, research and using the library. Participants were often overwhelmed with feelings of anxiety and low self-confidence as they learnt how to navigate the university system, balance their roles and use newly developed new skills.

Weren't quite sure what you needed to know and it was all very new. What do I study? Where do I sit? Probably that next 6 months period it took me to learn that and I felt like I floundered a bit when I first started. (Participant 4)

Most of the literature about anxiety in nursing students focuses on clinical practice, rather than on the anxiety related to theoretical learning^35,36. This is a significant finding because the high levels of anxiety relating to theoretical study suggests a need for the development of support programs and stress reduction programs to be available during the first few months of enrolment.

For participants, being organised and being good time managers were the factors that enabled them to perform all their roles adequately. These findings confirm previous studies^9,37,38 that found time management to be a significant factor for students. While participants in the present study believed they had good time management skills and were able to manage their numerous roles, the pressure of university often led to prioritising study over household chores and family life, resulting in feelings of inadequacy and guilt. For example, one participant explained that her children were unable to have friends to sleep over because she could not manage having to organise activities and care for others as well as her own family. She went on to say how guilty she felt because she perceived her children were missing out on elements of their childhood due to her commitment to becoming a registered nurse.

During this period participants recognised that it was essential to have members of the family participating in household duties. Although Inglehart and Norris³⁹ maintain that in post-industrial societies women are able to remain in the workforce, creating dual earning families, the division of household labour has not markedly changed leaving working women to juggle multiple roles and responsibilities. Furthermore, the literature supports the belief that mature female students juggle many responsibilities as they try to continue to undertake all their household and family related tasks^22,40-42. Conversely, Baxter and Britton⁴², in their study of 21 mature-aged undergraduate students, found that there were particular risks to family relationships related to gender divisions of household labour and responsibilities. These risks were found to be higher for the women than for the men in the study. Baxter and Britton's study suggests that mature women returning to study view a division of labour according to availability (of a person) and need, rather than according to gender.

Participants expressed feelings of guilt if they were unable to do what they perceived to be their 'household tasks'. Although they spoke of having supportive partners who helped with household chores and child care, it increased rather than diminished their feelings of guilt because they felt inadequate and unable to do what they expected of themselves. An exception to this was the one participant whose partner had given up work to become a 'house husband'. Although she had thought they had an equal division of non-gender-based labour in the house prior to undertaking her course, she was surprised to find that this was actually not the case and that the division of labour had been very gender specific. This participant was shocked to discover that her husband had no clear idea of what was involved in being a stay-at-home dad. This participant experienced feelings of resentment as she attempted to juggle full-time study, part-time work and home duties.

I realised that I was working and going to uni and trying to get a better job than the one that I had but I still seemed to be doing at least as much of the housework as I had before. You know, why did he give up to work to stay home with the kids if I was going to keep doing it? So in the end I just ended up with free babysitting I think, he had a free hobby. (Participant 3)

Minimal resources due to their rural environment (eg library facilities external to the university campus, child-care facilities, availability of public transport and student support services) were identified by all participants. Of particular concern to all participants was the lack of reliable and fast internet services in their areas. This affected their ability to open files, especially PDF files, and so they often had to make a long journey to the university to use computer facilities.

Retreating and regrouping

During the course of their study participants spoke of having times when their emotional integrity felt threatened. Often this feeling would be related to gaining a poorer grade than expected, or a lack of confidence as examinations loomed. At these times participants said that they needed to emotionally withdraw and provide themselves with 'time out' to reflect. Withdrawing to a place of emotional safety allowed participants to 'lick their wounds' or re-evaluate and return to university with renewed determination. Although all the participants spoke of considering withdrawing during these times, none of them actually did. Rather the emotional support, positive reinforcement and encouragement given to them by peers was cited as being the most significant factor that enabled them to get through these periods.

I'd go on a blinder - I'd call my friends and say I need time out and we would go out on the town together. (Participant 1)

My friends [the other students] they would ring up and come around and they wouldn't let me withdraw - they said you can do it. (Participant 5)

Interestingly, participants felt that clinical placements, although beset with unique anxieties and stressors, provided some time out from university. However the participants from university A also said that increasing theoretical demands were making clinical practice difficult because they often had to work their 8 hour shift and then follow it up with a further 2 to 4 hours of case study writing or presentation preparation. It was felt that the clinical practice experience was difficult enough without adding additional theoretical loadings.

A further problem highlighted by participants at these times was their rurality. Participants were not always geographically close to family and friends and so had to rely on the phone and email for support. However, significantly, participants acknowledged that their major support came from each other. Participants believed that only other mature age students could truly understand their issues, and so a close relationship with other mature age students was crucial to their ongoing coping. These findings concur with previous studies that found mature students have a complex support network that include financial, physical and emotional support provided by family, friends and academic staff⁶. The importance of peer support from other mature-aged undergraduate students is also highlighted by Kevern and Webb⁹ who assert that this support is based on friendships grounded in mutual understanding and empathy. Similarly, Phillips and Pugh⁴³ advise mature-aged undergraduate students to establish a network of peers and get together and talk about their issues, their experiences and their strategies for dealing with competing responsibilities.

Soldier on

Navigating the journey required enormous tenacity and all participants verbalised their determination and motivation to succeed. Indeed, resilience and tenacity are factors that help mature students to keep going when the going is tough. Resilience involves successfully adapting to stressful situations through the use of positive coping mechanisms. Arguably, resilience is a combination of factors, a dynamic, ongoing process rather than a specific skill. This process involves building adaptive mechanisms that empower the person to adapt to stressful events and achieve positive outcomes. Resilience is strengthened as the person confronts and positively adapts to subsequent events.

You have had a hard day at uni and you come home and you really just pretty much want to crawl into bed but you can't because there are things to be done. (Participant 5)

I took a breath every day and hoped for the best! (Participant 3)

I think I just picked myself up and dusted myself off and told myself you can do this - you've gone this far and I think it was just trying to give myself the courage. (Participant 4)

Although resilience is often developed through experience, it can also be learned. The expressions resilience and courage are often used concurrently⁴⁴. Conversely, Benard⁴⁵ believes everyone is born with resilience and the ability to further develop resiliency capabilities. He cites social competence, problem solving, autonomy, a sense of purpose and a belief in the future as being the features of resilience. These traits were displayed by participants who described a clear sense of the future and spoke of their future in positive terms. Participants expressed their growing independence, autonomy and problem solving.

Once you achieve something at a certain level you set up a whole heap of other expectations for yourself. You realise that learning isn't an end point, it's only a gateway to learn more things. (Participant 2)

I am standing on my own two feet and making my own decisions. (Participant 1)

While some educational literature identifies the importance of tenacity in mature-aged undergraduate students and its relationship to course completion^46-49, little has been written about the defining characteristics of tenacity, nor its significance to students during their time at university. Goldbeck-Wood⁵⁰ asserts that mature-aged undergraduate students possess levels of motivation, tenacity and commitment that are not found in younger students. Khalil⁴⁸ concurs, arguing there is considerable tenacity among mature-aged undergraduate students that facilitates them overcoming challenges to complete their courses. All the participants in the present study exhibited tenacity. They spoke of 'keeping going', of 'being determined to succeed' and 'being focused on that goal of becoming a registered nurse'. Although some students naturally encountered more extreme obstacles, all students confronted enormous challenges to succeed.

Despite the paucity of literature concerning mature age students and tenacity, university information brochures for mature age students cite personal tenacity as being a necessary quality. Mature age students have to overcome numerous challenges to remain in university, and their determination is the single most significant motivating factor to keep them going, despite numerous challenges. Rudel⁵¹, in her study concerning retention among non-traditional students, found that tenacity was a common and significant characteristic in older nursing students.

Participants identified that because they lived in a rural environment they were often well known in the community. People in their community knew they were going to university to become a nurse and were supportive and encouraging of this. This community involvement would be uncommon in most urban environments and was viewed by participants as being supportive and to have increased their tenacity to succeed.

The victory march

The final leg of the mature students' journey is the completion of the degree. This completion is marked by both positive and negative feelings. While participants spoke of a great sense of achievement and pride in attaining their goal, they also spoke of the anticipated difficulties in disengaging from university culture.

Friday was an odd day. I couldn't believe it was all over. I have such a sense of accomplishment and am so proud that I got there. (Participant 1)

We are so glad that we are finished, and with the graduation I sort of was umming and ahhing whether to go and [the family] all said no, you are going. That is our chance to celebrate with you. We don't care if you don't want to celebrate, we want to celebrate. We did it together! (Participant 4)

It's all a bit scary and I have thought about how I will manage because I will be going rural and I won't have everyone here to support me so I'm kind of starting to step away now. (Focus group participant 1)

There is little in the literature that describes the experiences of students in this final stage of their university journey. Anxiety, although coupled now with elation, still pervades the students self-confidence as they begin another transitioning stage.

I can see I am in a stage of transition but it's scary. I know university now, I know what to do here - it's safe. (Focus group participant 3)

In rural communities where the population has watched the participant study and has encouraged and been interested in their progress, the community members are proud of the accomplishment.

They were all so pleased for me and everyone knew. It made me feel so proud of what I had accomplished. (Focus group participant 1)

Limitations

This study has three limitations. The first is that no male participants were recruited. This outcome was unintentional and despite specific unsuccessful attempts to recruit male participants. The lack of male students may have been due to the limited number of mature male undergraduate nursing students at the rural campuses, or simply a lack of interest or insufficient time. Thus, there was a potential for bias due to all participants being female. Indeed, the university journey and the way it is navigated may well be different for mature male students. The second limitation is the extent to which findings can be generalised beyond the Australian context. However, these limitations identify potential opportunities for future research. Finally, participants were all within the final 18 months of their course and so had completed half the course. Although these participants were interviewed throughout the remainder of their course, it does place a limitation on the study.

Summary

This grounded theory study found that the journey undertaken by female mature undergraduate nursing students at two rural Australian universities could be explicated in stages. These stages were explored within the themes of initiating the crusade, engaging the force, retreating and regrouping, soldiering on and the victory march. The findings indicated that mature students developed informal networks of support among themselves that helped them get through difficult times. Although this is not dissimilar to younger students who also develop informal support, female mature students cited these informal supports as being the most significant factor in helping them to cope with course demands. The constant need to balance their varied roles required mature students to refine existing and learn new coping strategies. Harnessing support and intrinsic tenacity helped mature students develop these new coping strategies. Sound organisational skills, good time management and reliable support networks were important factors that enabled students to maintain their varied roles and responsibilities.

Conclusions

While it is necessary to realize that the mature age nursing student's journey may take numerous twists and turns, this study provides an explanation of the various stages mature students traverse when undertaking university studies. Good support networks, sound organizational skills, resilience and tenacity are factors that assist the mature student throughout their studies. Participants identify rural factors such as poor resources, minimal formal supports, travel time and travel costs as impacting on their university lives. However participants also acknowledge that life's experiences and maturity give them an advantage over younger students.

Mentoring programs need to be established in universities for senior mature-aged undergraduate students to mentor junior mature students. The need for appropriate matching of students is a significant finding in this study. While students acknowledged the existence of mentoring programs, they asserted that the inappropriate matching of mature-aged students with young students meant that the programs were ineffective.

It is further recommended that mature-aged students are introduced to developing their professional portfolios and that mentoring courses become a component of these portfolios. These courses should be validated by professional organisations such as the Royal College of Nursing Australia as professional development initiatives that are accessible to students, cost-free.

It is also suggested that student support programs are developed to meet the needs of mature-aged students, and that information on finances, academic matters, personal counseling and childcare services are readily available. Furthermore, there is a need for timetable flexibility, especially in rural universities, to diminish the requirement for students to attend university for short spans of time. Professional career counseling services are proposed, particularly for final year students. These services may help ameliorate the anxiety associated with disengaging from university and seeking employment. Professional career counseling services must incorporate assistance with preparing employment applications, especially those in the public sector that involve addressing selection criteria. These support services will also assist students to begin to prepare psychologically for their transition to the workforce. Finally, the establishment of retention committees at universities is advocated. Such committees should examine the reasons for withdrawal from courses, and establish polices and practices to support students and increase retention.

Unlike younger students, the decision to study has been a conscious decision for these participants. In order to study they have made sacrifices and rearranged their and their family's lives. The journey itself is as important as the outcome for these students. Educators need to be aware of how rurality impacts on mature students learning, as well as their ability to undertake a baccalaureate degree. Educators have a role in proactively facilitating mature student networks, as well as in implementing support strategies to assist mature students in their soldiering on.

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