Online NP Students Taking Multiple Clinical Courses Per Quarter
This paper presents a retrospective study examining grade outcomes for online nurse practitioner (NP) students who enrolled in more than one clinical course per quarter (OCCPQ). Using data from 3,760 NP graduates from fall 2013 through spring 2016, the study found that students taking multiple clinical courses per quarter had significantly higher odds of failing a clinical course on first attempt (OR: 2.77, 95% CI: 1.53–5.02, p=0.001). Subgroup analyses revealed that this risk was concentrated among students who took multiple clinical courses in only one quarter, and that the effect was more pronounced among African-American students than white students. The paper discusses self-selection bias, the absence of prior literature on African-American adults in online nursing education, and recommends that NP programs advise students to weigh personal and professional obligations before increasing clinical course load.
- Introduction and Study Overview: Background, sample, and primary statistical findings
- Discussion of Findings: Main result linked to prior online learning literature
- Course Load and Self-Selection Bias: Why multi-quarter students show no increased failure risk
- Race and Ethnicity Subgroup Analysis: Higher failure odds for African-American students
- Limitations and Future Directions: Generalizability gaps and prospective research needs
- Conclusion and Program Recommendations: Advising NP students on course load decisions
- References: Cited sources supporting the study
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What makes this paper effective
- Presents concrete quantitative findings — odds ratios, confidence intervals, and p-values — grounding the discussion firmly in statistical evidence rather than anecdote.
- Uses a large retrospective sample (n=3,760) drawn from a defined graduation cohort, lending credibility to the primary comparisons between single- and multiple-clinical-course enrollees.
- Engages honestly with the limits of the data, acknowledging the absence of prior literature on African-American adults in online nursing education rather than overstating comparisons.
Key academic technique demonstrated
The paper demonstrates multivariate logistic regression with stratified subgroup analyses. By first reporting an overall odds ratio and then disaggregating findings by the number of quarters in which students took multiple clinical courses — and further by race/ethnicity — the authors show how layered regression models can isolate the conditions under which a primary association holds, weakens, or disappears. This technique controls for confounders such as age, specialty, and race while still allowing meaningful subgroup comparisons.
Structure breakdown
The paper opens with a structured abstract summarizing the research question, sample, key findings, and recommendations. The discussion section then moves in logical order: restating the primary finding, connecting it to prior literature on online course load, explaining the self-selection interpretation for the multi-quarter subgroup, reporting the race/ethnicity stratified results, and closing with limitations and program-level recommendations. Four statistical tables are appended, presenting demographic characteristics, grade outcome comparisons, and two logistic regression models.
Introduction and Study Overview
The shortage of primary care physicians has increased demand for nurse practitioners (NPs). Online NP programs are of particular interest to working students who face personal and professional life demands. This study examines grade experience differences for students in an online NP program who took more than one clinical course per quarter (OCCPQ) compared to those who did not.
This retrospective study consisted of 3,760 NP students who graduated between fall 2013 and spring 2016. Students who took more than OCCPQ had a greater percentage of clinical course failures on first attempt than those who did not (2.1% versus 0.8%, p=0.001). Multivariate logistic regression adjusting for relevant covariates confirmed these results, showing increased odds of clinical course failure on first attempt for those who took more than OCCPQ (OR: 2.77, 95% CI: 1.53–5.02, p=0.001).
NP programs should communicate to students that taking more than one clinical course per quarter is associated with a higher risk of clinical course failure. Programs should emphasize that students carefully consider their personal and professional time commitments before deciding to enroll in more than one clinical course per quarter.
Discussion of Findings
We found that NP students who took multiple clinical courses per quarter had increased odds of failing a clinical course on first attempt compared to those who enrolled in only one clinical course per quarter. Analyses that evaluated the number of quarters in which students took multiple clinical courses found this association — increased odds of failing a clinical course on first attempt — only among those who did so for a single quarter. Students who took multiple clinical courses per quarter across two or more quarters were not associated with increased odds of failure on first attempt. This pattern held for both white and African-American students.
These findings align with those of Bambara et al. (2009) and Roblyer (2006), who identified increased course load as a stress factor in online learning environments. Bambara et al. examined students enrolled in high-risk courses — those with elevated failure rates — and noted that students fail for many reasons, including both academic challenge and the social isolation inherent in online coursework. Students who respond well to academic challenge tend to complete the course, while those who struggle often lack the resources needed to persist, which accounts for higher failure rates in that group. Roblyer examined a different population — high school students — but similarly focused on why students struggle in online programs. Roblyer found that one advantage of online education is the ability to tailor flexible course loads: students who need a lighter load can pursue one and are more likely to complete their studies. Together, these studies demonstrate that course load is a contributing factor in online course completion, though other factors must also be considered.
Course Load and Self-Selection Bias
In analyses examining students who took multiple clinical courses per quarter over multiple quarters, only those who did so in a single quarter showed increased odds of failing a clinical course on first attempt. Those who took multiple clinical courses across more than one quarter did not show any associated increase in odds of failure.
This pattern likely reflects self-selection bias. Students who continue to take multiple courses per quarter across multiple quarters are those who demonstrated on their first attempt that they could manage the workload. Some students may initially fail a course while overestimating their readiness to handle both the challenges of an online learning environment and the rigorous demands of NP education. Students who succeed on their first attempt are more likely to continue with a heavier course load in subsequent quarters, while those who fail are unlikely to repeat the same pattern. This suggests that first-time failure may serve as a corrective signal, and that students who persist with multiple clinical courses per quarter self-select into a higher-performing group over time.
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