Manuscript Discussion The Grade Experience of Online Nurse Practitioner Students Who Took More Than One Clinical Course Per Quarter

The shortage in primary care physicians has increased the demand for nurse practitioners (NPs). Online NP programs are of interest to working students with other personal and professional life demands. This study examines grade experience differences for students of an online NP program who took more than one clinical course per quarter (OCCPQ) as compared to those who did not take more than OCCPQ. This retrospective study consisted of 3,760 NP students who graduated between fall 2013 through spring 2016. Those who took more than OCCPQ had a greater percentage of clinical course failures at first attempt as compared to those who did not take more than OCCPQ (2.1% versus 0.8%, p=0.001). Multivariate logistic regression adjusting for relevant covariates maintained these results with increased odds for clinical course failures for those who took more than OCCPQ at first attempt (OR:2.77, 95% CI:1.53, 5.02, p=0.001). In conclusion, NP programs should communicate to NP students that some students taking more than OCCPQ fail the clinical course. NP programs should emphasize to students that students should consider the time commitments from their personal and professional obligations before deciding upon taking more than OCCPQ.

Discussion

We found that NP students who took multiple clinical courses per quarter had increased odds of failing a clinical course at first attempt than those who only enrolled in one clinical course per quarter. Analyses that evaluated the number of times taking multiple clinical courses per quarter only found this association for of increased odds for failing a clinical course at first attempt among those who did this for one quarter. Those who took multiple clinical courses per quarter two or more times were not associated with increased odds of failing a clinical course at first attempt. This pattern of increased odds for failing a clinical course at first attempt among those who did this for one quarter occurred both among whites and African-Americans.

We found that NP students who took multiple clinical courses per quarter had increased odds of failing a clinical course at first attempt than those who only enrolled in one clinical course per quarter. This is in line with the findings of Bambara et al. (2009) and Roblyer (2006) who identified increased course load level as a stress factor. Bambara looked at students who enrolled in high-risk courses (i.e., those with high failure rates). The authors of this study noted that there are many different reasons for students to fail, including both academic challenge and the social isolation that derives from being in an online course. Students who respond well to academic challenge tend to finish the course, but students who struggle with academic challenge often find themselves lacking the resources they need to push through, and it is from that where the higher failure rates occur. Roblyer looked to a different population -- high school students, but also with a focus on the causes for students to struggle with online programs. Roblyer found that one of the advantages with online schools is the ability to tailor flexible course loads -- students who need a lighter load can have it, and are more apt to complete their studies. What both of these studies show is that there are other factors besides course load that affect the ability of students to complete online courses. Course load is a factor, but there are other factors that should be taken into account as well.

We found in analyses for taking multiple clinical courses per quarter multiple times that only those who took multiple clinical courses for one quarter had this increased odds for failing a clinical course at first attempt. However, those who took multiple clinical courses for more than one quarter did not have any association with increased odds for failing a clinical course at first attempt. This is likely a case of self-selection bias. Students who take multiple courses per semester over multiple semesters are going to be the students who demonstrate the first time they try that they can handle the workload. So while some students might fail a class on their first try, only ones who succeed on their first try are going to continue to take multiple courses in subsequent semesters. Among those who fail, they may initially think they are prepared to face both the challenges associated with online learning environment as well as the rigors of NP education, but they might be lacking adequate supports.

In the analyses stratifying for white and African-American race/ethnicity, we found that the magnitude of odds for failing a clinical course at first attempt among those who took multiple clinical courses for one quarter was higher among African-Americans than whites. Unfortunately, there is no prior literature on this direct subject to compare our findings to. There do not even appear to be studies conducted on African-American adults in online education regardless of subject, so it is not possible to compare our findings to other studies.

This study has several limitations. First, this was conducted with an online NP program and may not generalize to traditional face-to-face programs. Second, there are potentially relevant psychological and psychosocial variables that may be relevant for understanding course failure. Future research should use a prospective design and obtain such relevant psychological and psychosocial information.

In conclusion, NP students taking more than one clinical course per quarter have increases odds for failing a clinical course. NP programs should communicate to NP students that some students taking more than one clinical course per quarter fail the clinical course. NP programs should emphasize...

We would like to especially thank Andrea Lindell, Dean School of Nursing, Max Lil, Senior Manager, Academic Advising and Jenna Kruse, Field Education Coordinator Supervisor for their support on this project.