Depression, Stress, Emotional Support, and Self-

Esteem among Baccalaureate Nursing

Students in Thailand
Ratchneewan Ross, Kent State University
Richard Zeller, Kent State University
Pakvilai Srisaeng, Khon Kaen University, Thailand
Suchawadee Yimmee, Kent State University
Sujidra Somchid, Burapha University
Wilaiphan Sawatphanit, Burapha University

Abstract
Nursing students are valuable human resources. Detection of potential depression among nursing
students is crucial since depression can lead to low productivity, minimized quality of life, and suicidal
ideas. Identifying factors affecting depression among students can help nursing educators to find ways
to decrease depression. The purpose of this study was to examine rates of depression and the
associations between depression and stress, emotional support, and self-esteem among baccalaureate
nursing students in Thailand. This correlational, cross-sectional study recruited 331 baccalaureate Thai
nursing students. Students completed three instruments that had been translated into Thai: The Center
for Epidemiology Studies Depression Scale, Perceived Stress Questionnaire, and Rosenberg Self-
Esteem Scale. Another instrument created in Thai was used to measure emotional support. Results
revealed that, when using the standard definition, 50.1% of the students were depressed. Stress was
positively related to depression, whereas emotional support and self-esteem were negatively related to
depression.

Recommended Citation
Ross, Ratchneewan; Zeller, Richard ; Srisaeng, Pakvilai; Yimmee, Suchawadee; Somchid, Sujidra ; and
Sawatphanit, Wilaiphan (2005) "Depression, Stress, Emotional Support, and Self-Esteem among
Baccalaureate Nursing Students in Thailand," International Journal of Nursing Education Scholarship:
Vol. 2 : Iss. 1, Article 25.
DOI: 10.2202/1548-923X.1165
Available at: http://www.bepress.com/ijnes/vol2/iss1/art25
 Nursing in the Public Schools of the United States of America
Maria Applewhite,RN
April 2003

A Historical Perspective of School Nursing in the United States

1. The Beginnings
2. The 1950’s, 60’s and 70’s
3. The Role of the School Nurse Today

Health Issues

1. The Medically Fragile Child and the Student With Special Health Care Needs
2. Infectious Diseases
3. Asthma
4. Obesity
5. Attention-Deficit/Hyperactivity Disorder (ADHD)
6. Pregnant and Parenting Teenagers
7. Substance Use and Abuse
8. Eating Disorders
9. School Violence
10. Gay Teens – Preventing Self-Harm

Professional and Legal Issues

1. Documentation
2. Research
3. Issues of Confidentiality
4. Who Has Access to a Student’s Health Record?
5. Accessing Health Care
 The Future
1. Pediatric Nursing Advances
2. Creating a Coordinated School Health Program
3. Participation in Public Policy, Legislative and Regulatory Government Relations

References

School Nursing: A Historical Perspective

The Beginnings
The late 19th century change from an agricultural to an industrial economy profoundly
influenced the health of children in the United States. Children were hazardously employed along side
their parents in mines, mills and factories. They were overworked and underpaid. They went home at
night to crowded and often filthy and dangerous living conditions. Undernourishment was the norm.
Healthcare was generally out of reach. Epidemics became commonplace, and the number of
preventable deaths, particularly among children of the poor, soared. Nowhere was the urgent need to
stop the spread of communicable diseases, particularly tuberculosis, more apparent than in the New
York City, where in 1902, 15 to 20 children were being sent home from every public school each day.

It was clear to Lilian Wald, a prominent public health nurse and social reformer, that the
protocol for school health in NYC, one of inspecting and dismissing children from school, was not only
failing to stop the spread of epidemics, but it was in fact making the situation worse. Though children
were being sent home with notes to their parents, these notes could either not be understood by the
immigrant community, or in those cases where the notes were understood, the health measures
indicated were not within their reach. As a result, excluded children simply ran the loose in the
community, and contagion continued to be rampant. Wald went to the New York City Board of Health,
and asked them to examine the quandary of contagion versus absenteeism. She proposed a new model
for school health for NYC schools, one that focused on treating children and keeping them in school.

The NYC Board of Health reluctantly agreed to a one-month trial period in four NYC schools,
with one nurse, Lina Rogers. Rogers would treat students for their disorders and return them to the
classroom. When the one-month timeframe was up, there was no question that significant
improvements had been made. The students in these four schools appeared healthier and had missed
significantly less classroom time, when compared to those students in other schools where no nurse
was present. Rogers was subsequently appointed by the NYC Board of Health, to be the first
municipality-sponsored school nurse in the United States.

School Nursing in the 1950’s, 60’s and 70’s:

Over the next several decades, by the middle of the 20 th century, along side the great strides
made in housing conditions and urban sanitation, and the development of vaccines and antibiotics, the
role of the school nurse began to shift. Duties evolved away from the model of treatment and towards
one of illness prevention and health education.

With the 1950’s and ‘60’s, many new health and welfare programs emerged. This marks the
beginning of the overextension of the role and responsibilities of the school nurse (Schumacher, 2002).
School nurses began to use those in the educational community to help them – administrators, teacher,
parents and at times, students. Often school nurses found themselves performing non-nursing tasks, and
those in the educational community found themselves performing nursing duties (as the number of
school nurses were few) (Shumacher, 2002).

Then came the 1970’s, and issues such as sexually transmitted diseases, teenage pregnancy and
drug dependency emerged. School health programs were forced to expand and adapt even further, and
the professional duties of school nurses, once again, became increasing overwhelming. With this rapid
over-extension of responsibilities, time constraints forced school nurses to cope only with the
immediate health problems of their students and only meet minimal state mandates. They were stuck
between models of education and nursing. They worked under non-medical norms, and had few
universally accepted goals and means for achieving them (Shumacher, 2002, Wolfe, 2002). They were
no longer able to produce tangible health outcomes that proved their worth, such as those produce by
Lilian Wald in 1902.

A congressional finding in 1975 found that one half of the 8 million disabled children in the
U.S. did not receive appropriate educational services and that one million children had been excluded
entirely from the public school system. This prompted the passing of the Public Health Law 94-142,
also known as the Education for All Handicapped Children Act. This law ensured that all students –
regardless of physical or mental disabilities – the right to a “free and appropriate public education” in
the “least restrictive environment.” The passage of this law was yet another watershed event in the
history of school nursing, as school nurses were asked to take on the complex health care needs of this
new population of students that was rapidly expanding due to continuing medical strides in fields from
neonatal care to medical technology. New school nursing duties now included gastro and nasogastric
feedings, oxygen administration, oropharyngeal, gastric and tracheostomy suctioning, respiratory care,
urinary catheterization, ostomy care, and monitoring of shunt functioning. School nurses, once again,
found themselves even more overworked, under funded and in their catchall positions (Constante,
2002).

The Role of the School Nurse Today

As school nursing enters the 21st century, the composition of today’s student population
continues to change, particularly in relation to the number, complexity and acuity of medical and
psychiatric problems with which students come to school. Students come to school with every actual
and potential physical and mental health condition, disability and treatment modality possible except
those requiring acute, in-patient treatment in a hospital. Additionally, much of today’s school
population is rife with poverty, homelessness, single-parent households, working parents, drug and
alcohol abuse, eating disorders, teenage pregnancy, suicide and violence. Other factors that affect the
health of the American student is that he or she has a one in four chance of living in a home with
substance abuse and/or drug addiction (Lowrey, 1995), a one in five chance of not having health
insurance, a one in 12 chance of suffering from asthma, and the greatest chance of the 10 most
industrialized nations in the world, to die in adolescence from medical or social causes
(www.gnofn.org).

In response to the diverse needs that challenge school communities today, the National
Association of School Nurses has specified seven specific roles for the school nurse of the 21st century.

1. The school nurse provides direct health care to students and staff: Health care may involve
treatment of health problems that are a result of injury, acute illnesses or a chronic health
condition. Chronic health conditions involve the development of an individualized health plan
(IHP) that should include an emergency action plan. The school nurse is responsible for
medication administration and the performance of health care procedures that are within the
 scope of nursing practice. The school nurse also assists faculty and staff in monitoring chronic
health conditions.

2. The school nurse provides leadership for the provision of health services: The school nurse
must take into account the nature of the school environment, including available resources. This
leadership role includes developing a plan for responding to emergencies and disasters and
training staff to respond appropriately. It also involves the appropriate delegation of care within
applicable laws.

3. The school nurse provides screening and referral for health conditions: In order to address
potential health problems that are barriers to learning or symptoms of underlying medical
conditions, the school nurse often engage are screening activities. Screening activities may
include vision, hearing, postural, body mass index or other screening. Determination of which
screenings should be performed is based on several factors, including legal obligations, the
validity of the screening test, the cost-effectiveness of the screening program, and the
availability of resources to assure referral and follow-up.

4. The school nurse promotes a healthy school environment: The school nurse provides for the
physical and emotional safety of the school community. The school nurse monitors
immunizations, assures appropriate exclusion from and re-entry into school, and reports
communicable diseases as required by law. The school nurse provides leadership to the school
in implementing precautions for blood borne pathogens and other infectious diseases.

5. The school nurse promotes health: The school nurse provides health education by providing
health information directly to individual students, groups of students, or classes or by providing
guidance about the health education curriculum, encouraging comprehensive, sequential and
age appropriate information.

6. The school nurse serves in a leadership role for health policies and programs: The school
nurse participates in and provides leadership to coordinated school health programs,
crises/disaster management teams, and school health advisory councils. The school nurse
participates in measuring outcomes or research, as appropriate, to advance the profession, and
advocates for programs and policies that positively affect the health of students or impact the
profession of school nursing.

7. The school nurse serves as a liaison between school personnel, family, community and health
care providers: The school nurse participates as the health expert on Individualized Education
 Plans and 504 teams and on student and family assistance teams. As case manager, the nurse
communicates with the family, community health providers and community health care
agencies. The school nurse ensures appropriate confidentiality, develops community
partnerships, and serves on community coalitions to promote the health of the community.

The National Association of School Nurses has determined that the minimum qualifications for
the professional school nurse should include licensure as a registered nurse and a baccalaureate degree
in nursing (BSN) from an accredited college or university. The growing complexity of nursing in the
school environment is mandating and increasing number of states to require master’s level education.
In addition, school nurse certification or licensure is recommended or required depending on the
individual state board of health.

Despite these expanded roles for the school nurse, as well as the many changes that have
occurred in school nursing and student health, the role of the school nurse today is fundamentally no
different that the role of Lina Rogers in 1902. It remains a practice that uses nursing knowledge and
skills to intervene effectively in order to improve the health and educational outcome of children and
adolescents.

Specific Health Problems That Effect the School Nurse Today

Students Who are Medically Fragile, or Who Have Special

Health Care Needs:
The school nurse has a unique role in the provision of school health services for children with
special health care needs, including children with chronic illnesses and disabilities of various degrees
of severity. These children are included in the regular school classroom setting as authorized by federal
and state laws. As a leader of the school health team, the school nurse must assess the student’s health
status, identify health problems that may create a barrier to educational progress, and develop an
individualized Health Plan (IHP) for management of health related problems in the school setting. The
school nurse also assists the school staff and pupils to understand the handicapped students special
needs, and serves as the liaison with physicians and allied health personnel relating to the evaluation
and provision of services to handicapped children. Naturally, part of working with a special needs
population is helping them understand, accept and adjust to their special needs.
 The school nurse must safely and effectively provide specific health care procedures. This
includes tracheostomy suctioning, bladder catheterization, ostomy care, nasogastric feedings,
maintenance of orthopedic devices and ventilator care, for students who need them. The school nurse
also should collect important information, such as special needs, modifications to routine medical
procedures, allowance to administer medications in school, emergency measures and parent permission
to interact with the student’s health care providers.

The courts are currently divided about how much responsibility school districts bear for
children who require constant and extensive nursing services in order to benefit from their education
(AFT, 2001). Generally, if the care required is intermittent and can be provided by a regular school
nurse, the service is an eligible service, but if the care required is more like private duty nursing, the
service is an excluded medical service. Because of conflicting interpretations by the courts, school
district obligations vary from state to state.

Immunizations
The school nurse is in a position to assess immunization needs and serve in a leadership
capacity to develop school immunization programs and promote community awareness of the value of
immunizations in the primary prevention of disease throughout the lifespan. Specific immunization
issues include, but are not limited to the following:

Lapsed or Uncertain Immunization Status:

This is a common situation in a mobile society. Families move to new communities. Children
are moved to live with relatives or to foster care. Children are adopted from foreign countries. Records
are lost or their validity cannot be ascertained. These are a few of many possible examples than can
throw a child’s immunization status into the categories of lapsed, unknown or uncertain. The terms
“unknown” or “uncertain” are self-evident and dictate the same course of action: assume that none has
been given and initiate an immunization schedule that is appropriate for age. No reliable evidence
exists that giving “extra shots” to someone who is already immunized does any harm; in fact, the
booster effect may do some good to enhance immunity.

Vaccine shortages:

Currently both the tetanus and the DTP vaccine supplies are almost depleted. This is a scenario
that is bound to become more common in the future. Fewer and fewer pharmaceutical houses are
producing vaccines for several reasons: hugely expensive development costs, small profits because
vaccines are purchased in bulk at discounted prices, and outlandish jury awards to persons injured by
vaccines. One or two manufacturers produce most vaccines in the US. When a production problem
arises, there may be inadequate reserve supplies to cover the period until full production is resumed.
During such periods, vaccine doses have to be rationed to those most at risk and routine immunizations
have to be deferred by the school nurse and other health care providers.

Bacterial Meningitis Clusters:

A case of bacterial meningitis requires notification by the school nurse to the parents of exposed
classmates. When a second case occurs, public health authorities should be notified immediately by the
school nurse in order to help determine the best course of action. Currently is recommended that
meningococcal vaccine be considered for freshmen college students living in dormitories, because of
their increased risk of meningococcal disease, but no recommendations are made for routine use of
meningococcal vaccine in other school groups.

Asthma
According to the American Academy of Allergy, Asthma and Immunology (1999), asthma is the
most common chronic disorder in children and adolescents, affecting about five million youngsters
under 18 years of age. Each year, children with asthma miss more than 10 million school days,
accounting for 60% of school absences (AAAI, 1999). Chronic absenteeism, whatever the cause, has
been shown to negatively affect grades, academic achievement, self-esteem, and future life successes
(Lenny, 1997).

Asthma is completely controllable. When students suffer from poorly controlled asthma, it is
actually the fault of noncompliant parents/guardians. The many reasons for this range from poor
parenting skills, low control of social and economic circumstances, to lack of energy to maintain the
often-rigorous schedule to control asthma symptoms. This is why the control of asthma, particularly in
the school setting is the implementation and adherence to an asthma management plan. Unfortunately,
poor adherence to a child’s asthma management plan may constitute medical, and subsequent
educational neglect. When clear and immediate risk is present for the child, referral to the appropriate
child protective agency must be made by school nurses (O’Toole, 2002).
Obesity
The single fastest rising public health problem in our nation is obesity (NASN, 2002). Over the
last two decades, the percentage of overweight adolescents has almost tripled. Currently in the U.S.,
13% of children 6 to 11 years of age, and 14% of teens 12 to 19 years of age are categorized as
overweight (NASN, 2002). Being overweight or obese is associated with several health risks. Children
who are overweight have an increased risk of high blood pressure, coronary heart disease, diabetes,
musculoskeletal disorders, early sexual maturation, psychosocial issues, and asthma. The also have a
greater risk of becoming obese adults than their classmates who are not overweight or obese.

The school nurse has the capacity to reach a large number of students, as well as parents, school
personnel and health care providers in identifying those individuals who are at risk for being
overweight or obese. Screening tools include height and weight measurement, skin fold testing and
measuring BMI (Constant, 2002). Weight issues are often dealt with by referring a child to his or her
health care provider and a subsequent nutritionist. They can also involve special doctor’s requests for
special meals to be provided by the school food services department. By helping students deal with the
problem of being overweight in a proactive manner, the impact of poor nutrition on learning outcomes
can be minimized (Costante, 2002).

Numerous studies over the past decade have provided evidence that girls in the United States,
especially African-American girls, are starting puberty at increasingly younger ages. Because
nutritional status is known to affect timing of puberty and there is a clear trend for increasing obesity in
US children during the past 25 years, it was hypothesized that the earlier onset of puberty could be
attributable to the increasing prevalence of obesity in young girls. Over the last couple of years, this
link has been found to be statistically significant (Kaplowitz, 2002). The results are consistent with
obesity’s being an important contributing factor to the earlier onset of puberty in girls.

Attention Deficit/Hyperactivity Disorder (ADHD)

The first medical description of ADHD appeared in literature in 1902, were it was described as
a defect in moral character and an unwillingness on the child’s part to inhibit his or her behavior (Spear,
2002). Today ADHD is defined as “a persistent pattern of inattention and/or hyperactivity-impulsivity
that is more frequently displayed and more severe than is typically observed in individuals at a
comparable level of development” (APA, 2000). Much of the literature now calls ADHD the most
commonly diagnosed psychiatric disorder of childhood (Spear, 2002). It is now thought that
somewhere between 5% and 10% of American school-age children (ages 5 to 18) have been diagnosed
with ADHD, with some studies going as high as 21% (Spear, 2002).

It is estimated that 12 to 50% of children with ADHD have also been diagnosed with other
psychiatric conditions from depression and anxiety disorders, to sleep difficulties, enuresis and
encopresis (Speer, 2002). Also significant to a diagnosis of ADHD, is that 25% of the students who
have been diagnosed with this condition also have a learning disability. Likewise, 25% of those with a
learning disability have been diagnosed with ADHD (Spear, 2002). [These are two completely different
conditions. Learning disabilities affect the brains ability to learn, whereas ADHD interferes with an
individual’s availability for learning (ADHD, 2002).]

Although some parents do not want their child to be labeled as having ADHD, the diagnosis is
the key to receiving treatment and school accommodations The school nurse is an integral member of
the necessary multidisciplinary approach in the assessment and diagnosis and treatment of ADHD
(Spear, 2002). And as they work with more children with ADHD than any other health care provider
and are knowledgeable about the symptoms, challenges, and treatment options for ADHD, then they
are in the best position to help these children and adolescents become healthy and productive adults
(Spear, 2002).

Pregnant and Parenting Teenagers

Teen pregnancy is an enormous and well-documented problem in the U.S., with about four in
ten teenage girls becoming pregnant before they reach the age of twenty. This translates to
approximately 890,000 teenage pregnancies in the U.S. each year, making it the highest teenage
pregnancy rates among industrialized nations (Hoyt, 2002; Spear, 2002). These pregnancy rates include
live births, induced abortions and fetal losses. They occur among almost all races and ethnic groups
(Hoyt, 2002, Clifford & Brykczynski, 1999).

The primary negative consequence of adolescent child bearing is decreased adolescent

attainment. Extensive research points out the links between adolescent childbearing and school failure,
low attendance, poor grades and school dropout rate (Casserly, Carpenter & Holcom, 2002). Generally
found to reduce schooling by 1 to 3 years, teen mothers have approximately a 60% chance of
graduating from high school by age 25, compared with 90% for those who postpone childbearing
(Casserly, Carpenter & Halcon, 2002). Other negative consequences include poverty, unemployment,
and children at risk for a variety of social and behavioral problems (Spear, 2002).

Many interventions and school health education programs have been put into place in schools
across the U.S. in hopes of reducing the soaring teen pregnancy rate. Research studies evaluating these
programs have these programs to be marginally successful. In fact, presently no program exists that
demonstrates significant delay of sexual intercourse, or affects contraceptive practices among middle
and high school students (Hoyt, 2002; Spear, 2002).

School nurses are in a unique position to make a difference in the substantial morbidity and
social problems that result from the pregnancies (Spear, 2002). They are in the logical position to select
and then implement programs that vary not only in length and intensity, but also in the populations they
target that vary according to age, culture and level of risk exposure. Should nurses are in the prime
position to evaluate both the short- and long-term outcomes of teen pregnancy reduction campaigns,
and becoming active participants in following pregnancy rates and identifying teen pregnancy trends
(Spear, 2002).

Additionally, a more comprehensive approach to school-based education is needed to meet the

complex needs of pregnant and parenting teenagers. School nurses should promote vocational training,
health services and on-site day-care, education on parenting and psychosocial support for mothers and
fathers, and their children. Additionally, they need to advocate for the completion of high school and
further education, economic independence and healthier outcomes for particularly young mothers and
their children (Spear, 2002).

Substance Use and Abuse

Substance use and abuse is a problem that impacts students from pre-school through high
school. Children of all ages may experience problems either related to living in a drug or alcohol
affected home or to abusing substances themselves. Family problems can include child abuse, fetal
alcohol syndrome, a change in the family dynamic that co-opts children in keeping the family secret,
depression, somatization, feelings of guilt, learning and academic problems, as well as genetic and
environmental factors that increase their own probability of substance abuse (Sullivan, 1995; Kinney,
1996). Problems related to personal substance use and abuse can include legal difficulties, academic
difficulties, truancy, dropping out of school, family difficulties, addiction, health problems, and
morbidity and mortality related to accidentally injury, homicide and suicide (Sullivan, 1995, CDC
2000). These students put their academic achievement at risk and can be a profound challenge to the
school nurse as a number of these students will present with behavior problems, health problems or
neglect (Sullivan, 1995). Because school nurses often participate in primary, secondary and tertiary
prevention activities in schools, they appear approachable and informed to students seeking help.
Therefore, the school nurse plays a key role in identification, support, and possible referral of students
impacted by substance use and abuse. Specific school nurse interventions would include making
appropriate referrals to agencies such as Social Services, Drug and Alcohol Treatment Services, Mental
Health services and the Child Protection Team; providing primary prevention/education to individual
students and classrooms; recognizing that students living in alcohol-affected homes may have a
multiplicity of alterations in academic achievement, social skills, affect and health; and evaluating and
referring students for concurrent mental health issues such as suicide risk. The needs of students
affected by substance use and abuse utilize a broad range of a school nurses nursing and community
health knowledge.

Eating Disorders
Eating disorders are among the leading health problems in the US. Typically diagnosed during
adolescence, initial symptoms of eating disorders “are becoming more prevalent…in elementary and
middle school years” (White, 2000). The most common eating disorders – anorexia nervosa, bulimia,
and binge eating – involve issues and behaviors around body image distortions, food and interpersonal
relationships. Eating disorders are serious, complex and sometimes fatal.

School nurses are uniquely prepared to assess and to formulate a nursing diagnosis and plan of
care for a student diagnosed with an eating disorder. As appropriate, the school nurse involves the
family or outside referral agencies for further evaluations. Surveillance for risk factors and prevention
through health education/support groups with at-risk youth provides an opportunity to identify students
early. The school nurse can play a vital role in the promotion of greater therapeutic success and greater
school success in the treatment of students with eating disorders.

School Violence
High profile violent incidents in schools make headlines and are sensationalized in news
reports. Lawmakers, parents and community leaders call for action to “make our schools safe again.”
The role of the school nurse is to collaborate with school and community members to implement
programs that will proactively change behaviors and lead to the creation of a positive, healthy and safe
environment. School nurse are active members of the crisis intervention teams and as such, assure that
their school community has an effective program in place. School nurses are also able to identify issues
related to self-esteem and self-worth, which can lead to isolationism and feeling of rejection among
students. School nurses address problems holistically, including examining the physical,

Emotional and social perspective of school violence. They are also able to contribute insight into
developmentally appropriate behaviors. and to recognize the early warning signs that may lead to
violence.

School nurse are also able to lobby for appropriate interventions and controls to address
violence against children, including local and national efforts to establish safe schools and
communities. This may lead to a coordinated interdisciplinary program that would include prevention
and early recognition and treatment of mental health issues.

Gay Teens – Preventing Self-Harm

As children and adolescents, gays (this term is used to refer to gay males, lesbians and bisexuals
of both sexes) go through the same developmental stages as heterosexual youth with the additional task
of trying to resolve the conflict between their sexual and/or gender feelings and society’s messages. Not
all gay teens resolve this conflict successfully. Suicide is the leading cause of death in gay youth (30%
of adolescent suicides are estimated to be committed by gay youth). Gay youths account for 30-35% of
the homeless youth in the US, with a four times greater incidence of being “kicked out’ or “forced out”
of their homes. HIV positivity is also high, particularly among gay male teens. Physical violence
toward gays is high in most areas, and a majority of bisexual and gay males report being verbally
abused by classmates on a regular basis.

The role of the school nurse is to find a way to signal gay students that their office/clinic is “gay
friendly” (displaying a gay poster or symbol). The school nurse needs to use non-biased language, such
as partner instead of girlfriend or boyfriend. A thorough sexual history is important and should include
questions about gender identify, sexual identity, age of first sexual intercourse, number of male and
female partners and history of sexual abuse or survivial-sex, keeping in mind that the gay person
remains gay regardless of his or her sexual behavior (Nelson, 1997).
 Professional and Legal Issues that Face the School Nurse Today

Documentation and School Nursing Research

Historically, the contributions of school nurses to the achievement of positive educational outcomes
have been largely invisible. This is because nursing documentation issues within the school setting lag
substantially behind other nursing settings. It is not that standardized nursing documentation languages
don’t exist, it is simply that they have for the most part, failed to be implemented in the school setting.
With no one universal standardized school nursing vocabulary, school nurses are unable to describe and
measure children’s health issues and the complex nature of professional school nursing practice, not to
mention how school health services contribute to educational outcomes. This lack of standardization of
data has made school nursing research very difficult. It is no wonder that there is poor public
comprehension of the value of school nursing, particularly as it relates to educational outcomes.

School nurses need to move towards a research-based practice that is able to scientifically
measure the cost-effectiveness, and the quality of outcomes of school health services and school
nursing (Hootman, 2002). Only when there is sufficient hard data to verify the connection of school
nursing services to educational outcomes for children, will school health services receive the funding it
needs to provide the educational outcomes that are mandated (Costante, 2002). School nurses must be
able to scientifically prove that health is fundamental to the educational process (Costante, 2002). Once
again, this begs for the practice of school nurses, to join other nursing specialties, and becomes
research-based.

Nationally there are approximately 30,000 nurses caring for 42 million students. That averages to
one nurse for every 1400 students. This is the situation despite the fact and the U.S. Department of
Health and Human Services, in its publication, Healthy People 2010, and the National Association of
School Nurses have issued recommendations for student to nurse rations to be 750:1 for the general
school population; 225:1 for the mainstreamed population; and 125:1 in special needs/medically fragile
populations (HHS 2002, NASN, 2002). It is doubtful that the poor student to nurse ratios that exist
today will change until school nurses can produce statistically significant data that proves the cost-
effectiveness of lower student to nurse ratios. School nurses are in a powerful position in the school
district, but only by expanding visibility can it be a viable one.

If school nurses cannot prove that what they do makes a difference or show what nursing
interventions are needed to ensure optimal student performance, then how can school nurses advocate
for increased school health services? Improved documentation systems will lead to smaller school
nurse to student ratios, the validation of specific school nursing interventions, and provide the basis for
establishing credible nursing services as they relate to positive educational outcomes.

Issues of Confidentiality
One of the most conflicting issues for school nurses is confidentiality of health information.
Conflicts about confidentiality exist between members of the school staff and the school nurse,
between parents/guardians and the school staff, and minors and their parents. School staff often believe
they have a right and responsibility to know all about a student’s personal health issues, whereas school
nurses are committed to protecting each individual student’s privacy related to health information
(Costante, 2002). Often a parent/guardian will not permit certain information to be shared with the
education team, despite the fact that school nurse might believe that some members of the school staff
could benefit from knowing about a student’s health status in order to serve him or her appropriately.
And thirdly, while parents generally hold legal authority to make health care decisions for their
children, there are sometimes divergent interests between what minors may want their parents to know
and parents/guardians feel is their right to know.

There are those who believe that minors with decision-making capacity, regardless of their age,
should be involved in their health care decisions (Dickey, 2002). There are those who believe the
opposite is true. The school nurse is often in a unique position to promote the inclusion of minors in
their day-to-day health care decisions, particularly as the health office is a “safe” place where students
can go for a variety of concerns without parental presence.

When a minor is married, pregnant, or a parent of his or her own child there are often state
statutes that allow for them to make autonomous decisions regarding health care for a variety of
service, including family planning, testing and treatment for HIV and other sexually transmitted
disease, prenatal care and delivery service, treatment for alcohol and abuse, and outpatient mental
health care (Dickey, 2002). This could, depending on the state, allow a 14 year old mother of an infant
leave school without parental permission to go to her 6-week post-partum check-up, or allow her to be
tested for a sexually transmitted disease, or even allow for the 16 year old father of the infant to leave
school without parental permission to accompany the mother and infant to a pediatrician’s appointment
(Schwab, 2002).
 Let’s say a minor is not married, pregnant, or a parent of his or her own child, what statutes
allow for them to make autonomous decisions regarding their own health care? Their rights to seek
health care independently of their parents are generally in proportion to the age and competence of the
minor, the type of health care the minor seeks (how invasive), and potential consequences to the minor
and the community if her or she refuses to seek care (such as the treatment of an STD, or the refusal of
to seek treatment for drug and alcohol problems) (Guidelines, 2002).

There is an active movement to ‘restore’ parental rights and to legislate parental control over
minors’ reproductive health care decisions. With the exception of abortion, lawmakers have generally
revisited attempts to impose parental consent or notification requirement on minors’ access to
reproductive health care and other sensitive services (Boonstra & Nash, 2002). Further complications
may arise with independent consent when parents are held liable for financial debt incurred by their
children when they did not have a say in the decision-making process (Dickey, 2002).

In health care, on the other hand, the legal rights of parents to make decisions for their children
gives way, in part, to the right of competent minors to seek and make their own decisions regarding
certain types of health care. In education, however, the legal right of parent to make decisions for their
minor children is upheld almost without qualification (guidelines, 2001). In this litigious age, this
paradox is not likely to be resolved, as it is becoming increasingly difficult for school nurses to defend
the autonomous health care decisions of minors as ethically valid (Dickey, 2002).

Who has Access to a Students Health Record?

The Federal Education Rights Privacy Act, also known as the Buckley Amendment, which was
passed in 1975, is a federal law that requires that students consent to parental access to their education
records. Are school health records education records or health records? FERPA does not provide special
protection for health information that a competent minor student may want to keep confidential, even
though, under state health laws, the information may be protected from access by others, including
parents. If a school nurse protects student health information, it often puts him or her at odds not only
with a federal law, but also with the expectations of school administrators and teachers regarding what
student health information school nurses can or should share with them.

Exceptions to FERPA are personal notes of the school nurse. In order for a notation to be
classified as a personal note, however, they must not be included in the health record, and they must not
be shared with any member of the education team. In other words, if a student discusses possible date
rape with a minor, he or she may choose not to document in the health record, and instead choose
simple to write a “personal note.” But in order for a ‘personal note’ to stay confidential, the school
nurse must not share its content with anyone, not even a social worker currently working with a family.
Once the ‘personal note’ is shared with anyone,’ it falls under the education law, FERPA, and allows
full parental access.

Currently there are no provisions, despite recommendations from the Centers for Disease
Control, to hold ‘personal notes,’ and/or health education records, to the same standards of
confidentiality observed in health care settings outside the office of the school nurse (guidelines, 2001).
Further complicating the issue is that in the school setting, is the fact that school nurses typically have
non-nursing on-site supervisors, most often the school principal.

Accessing Health Care

Accessing health care is broader than accessing medical care. In addition to medical care for
acute and chronic illness, health care includes health promotion and disease prevention services.
Unfortunately, not all children have an ideal connection with the health care system for comprehensive
health care. Multiple barriers to accessing comprehensive health care exist, including geographic,
financial, transportation, sociocultural, coverage criteria and availability of services.

Ensuring access to quality health care is an important component of school nursing practice.
Knowledge about the health care system (e.g. legal mandates, funding sources, and programming),
specific regional resources and health policies can bridge the gap between the health care needs of
students, their families, and school staff and accessibility to services. The school nurse can assist in the
elimination of geographic, transportational, sociocultural and financial barriers to accessing health care
by suing his/her knowledge and expertise about health needs and the health care system.

The Future of School Nursing

The Advanced Practice Nurse

The dynamic, expanding and comprehensive nature of the practice of school nursing
demands an educational and skill level that enables nurses to meet the complex health needs of
students. As the specialty of school nursing evolves, the requirement for a master’s degree will become
increasingly appropriate. Advanced Practice Nurse is a term used to identify the professional registered
nurse functioning in an extended role. This nurse must have a baccalaureate degree, as well as a
master’s degree, and/or certification as a nurse practitioner or a clinical nurse specialist.

The Advance Practice Nurse in the school setting will always be challenged by issues such as
teen pregnancies and medically fragile students, downsized staffing, and cultural diversity of school
populations. Costs prompt shorter hospital stays so that children are discharged earlier to home and
schools. School nurses need to keep pace with technological advances particularly those that address
students with special health care needs. Participation in professional organizations is paramount. These
not only include state and national school nurse associations, but also organizations that deal with
specific health care issues such as the American Diabetes Organization, National Education
Association, National Association of Nursing Research, and even the national Pediculosis Association.
The Advance Practice Nurse will promote improved quality of health services in schools. Educational
programs to expand the skills and scope of practice of the Advance Practice Nurse in the school setting
should be established in each state.

Coordinated School Health Program

Although the traditional childhood diseases have diminished, new health problems that have a
negative influence on student achievement and success have emerged. These “new morbidities” include
an increase in chronic health conditions such as asthma, allergies, diabetes, addictions, teen
pregnancies, HIV/AIDS, STDs, suicide and auto accidents. Many of these health problems are the
result of poverty, homelessness, poor nutrition, lack of exercise, smoking, early and/or unprotected
sexual activity, substance abuse, stress, and depression. The national Coordinated School Health
Initiative has emerged in response to the state of children’s health and education. It is an organized set
of policies, procedures, and activities designed to protect and promote the health and well being of
students and school staff. It is a holistic approach to health an education. The school nurse participates
actively in each of the eight components of a coordinated school health program. (The eight
components are: school health services, health education, health promotion programs for faculty and
staff, counseling psychological and social services, school nutrition services, physical education
services, health school environment and family and community involvement.)
Participation in Public Policy, Legislative and Regulatory
Government Relations
School nurses need to continue to promote public policy, and legislative and regulatory action,
which are favorable to students. It is imperative that professional school nurses continue to be involved
in the policy arena to impact the health and education of students and the practice of school nursing.
They need to advocate for the removal of health related barriers to educational success. Past successes
include the Supreme Court mandated inclusion of school nursing services in the federal law, IDEA, and
the inclusion of lower school nurse to student ratios in the objectives of Healthy People 2010. It is up to
the professional school nurse to take direct action regarding public policy that directly affects the well-
being of students as well as the his or her professional status.

References

American Academy of Allergy, Asthma and Immunology (AAAAI). (1999). Pediatric asthma:
Promoting best practice. Guide for managing asthma in children. Milwaukee, WI: Author.

American Academy of Pediatrics. (2001). The role of the school nurse in providing school health
services. Pediatrics, 108, (5), 1231-1232. Accessed 1/13/2003. http://www.aap.org/policy/re0050.html

American Academy of Pediatrics. Subcommittee on Attention Deficit/Hyperactivity Disorder

Committee on Quality Improvement. (2001). Clinical practice guideling: Treatment of the school-aged
child with Attention-Deficit/Hyperactivity Disorder. Pediatrics, 108, 1033-1044.

Boonstra, H., & Nash, E. (2000). Issues in brief: Minors and the right to consent to health care.
Retrieved February 9, 2002 from the World Wide Web: http://agi-usa.org/pubs/ib_minors_00.html

Brandt, D.C. (2002). Enhancing school nurse visibility. The Journal of School Nursing, 18 (1), 5-10.
Clifford, J., & Brykczynski, K. (1999). Giving voice to childbearing teens: Views of sexuality and the
reality of being a young parent. Journal of School Nursing, 15(1), 4-15.

Casserly, K.R., Carpenter, A.S. & Halcon, L. (2002). Adolescednt parenting: Relationship to school
attendance and achievement. The Journal of School Nursing, 17, (6), 329-335.

Costante, C.C. (2002). School health nursing: Framework for the future part I. The Journal of School
Nursing, 17, (1), 3-11.

Costante, C.C. (2002). School health nursing: Framework for the future part II. The Journal of School
Nursing, 17, (2), 64-72.

Dickey, S.B., Kiefner, C. & Beidler, S.M. (2002). Consent and confidentiality issues among school-age
children and adolescents. The Journal of School Nursing, 18 (3), 179-186.

Hootman, J. (2002). The importance of research to school nurses and school nursing practice. The
Journal of School Nursing, 18 (1), 18-24.

Hoyt, H.H.,& Broom, B.L. (2002). School-based teen pregnancy prevention programs: A review of the
literature. The Journal of School Nursing, 18(1),11-17.

Kaplowits, P. et at. Al (2002). Earlier Onset of Puberty in Girls. Pediatrics, 108(8), 347-353.

Kolar, K.R., Haynie, L., Wilkerson, R. & Fisher, W. (2002) Type 1 Diabetes in children and
adolescents: What’s new? The Journal of School Nursing, 18, (3), 344-348.

Lowry, A. (1995). Caring for America’s Children. The Maginnis Communique, February.

National Association of School Nurses. (1998) Standards of professional school nursing practice.
Scarborough, ME: Author.

National Association of School Nurses. Position statement: Caseload assignments. Accessed 2/24/03.
http://www.nasn.org/positions/caseloads.htm

National Association of School Nurses. Position statement: Overweight children and adolescents.
Accessed 2/24/2003. http://www.nasn.org/positions/overweight.htm

National Association of School Nurses. Position statement: School nursing yesterday and today.
Accessed 1/14/2003 http://www.continuingeducation.com/nursing/schoolnursingyt/profissue

Nelson, J.G. (1997). Gay, lesbian and bisexual adolescents: Providing esteem-enhancing care to a
battered population. Nurse Practioner, 22(2), 98-109.

Schumacher, C. (2002). Lina Rogers: A pioneer in school nursing. The Journal of School Nursing, 18,
(5), 247-249.

Schwab, N.C. & Pohlman, K.J. (2002) Legal and ethical issues: Questions and answers. The Journal of
School Nursing, 18, (5), 301-305.

Selekman, J. (2002). Attention-Deficity/Hyperactivity Disorder. The Journal of School Nursing, 18 (5),

270-276.

Spear, H.J. (2002). Reading,writing and having babies: A nurturing alternative school program. The
Journal of School Nursing. 18 (5), 293-300.

Stock, J.L., Larter, N., Kleckehefer,kG., Throsonn, & G. Maire, J. (2002). Measuring outcomes of
school nursing services. The Journal of School Nursing, 18, (6), 353-359.

Wolfe, L.C. (2002). School nursing: The next hundred years. The Journal of School Nursing, 18, (5),
250-251.
Linking Health to
Academic Success and Retention
Jim Gr i z z ell, MBA, MA, CHES, FACHA and Michael McNeil, MS

Student retention and academic success are top priorities

of universities, their re s p e c t i ve colleges/units and
students.1 Much of the research on why students are not
successful and leave does not succinctly provide classifying
reasons and fewer yet investigate health as a factor. A few
studies do give a glimpse at the positive associations
b e t ween academic success and health behaviors and status.
The university Student Health Service, including health
promotion, has improved health behaviors, health status
as well as academic performance and retention yet we are
rarely able to prove it. National health organizations offer
s u p p o rt and guidelines to inform and influence individual
and community decisions that enhance health, academic
success and retention.2
Defining Retention & Health
There are many different definitions related to
retention of students in higher education. Berger &
Lyons3 offer the following concepts:
Attrition: a student who fails to reenroll at a particular
institution
Dismissal: a student who is not permitted to continue
enrollment (by the institution).
Dropout: a student that was seeking a degree but fails to
complete and leaves the institution.
Persistence: the desire and action of a student to earn a
degree from a post-secondary institution.
Retention: an institutional ability to keep a student from
admission/enrollment to graduation.
St o p o u t : a student that temporarily leaves the institution.
Few would argue with the idea that the vast majority
of students enroll in post-secondary education to earn a
degree. Given this outcome-oriented motivation, it is
important that the field of college health examine the role
of health and health services in supporting student success
(graduation). Research shows that about one-third of
students beginning postsecondary education left without
a degree and there is limited information about how
health affects retention.

Exit surveys looking at why students leave the

university rarely ask in-depth questions about health and
the findings do not help Student Affairs and health
professionals determine priority health issues to address.
The ACT5 survey asked about the degree to which three
institutional factors and student characteristics we re re l a t e d
to attrition. The institution factor was “Academic Su p p o rt
Se rvices (learning centers, similar re s o u rces)” and ranked in
the middle of 24 factors. Student characteristics identified
that affected attrition were the degree of “Physical Health
Problems” and “Mental or Emotional Health Problems.”
Each ranked in the bottom five of 15 factors. Ad d i t i o n a l l y,
a third of students did not give a reason for leaving.
Somewhat specific reasons from one study with
729 student records from an upstate New York private
u n i versity show the broad description of why students leave .
Rummel6 found the following reasons for institutional
departure:
• No reason given (29.8 %)
• University dropped the student (28.9%)
• Personal reasons (19.9%)
• Found another school/transferred (11.5%)
• Academic (5.5%)
• Financial problems (3.8%)
• Medical problems (0.5%)
Why Retention Matters
Student academic success and retention are indicators
that the university is doing what it says — its re s p o n s i b i l i t y
and mission to provide an education and an academically
enriching experience. From the university’s perspective it
is less expensive to help current students succeed than to
re c ruit new students. Wa t s o n7 p rovides this basic example:
If the total recruitment/enrollment management
budget for Institution X is $1,000,000, and 6-year cohort
graduation rate is only 50%, then $500,000 is lost in
efficiency.
Additionally, good retention rates attract future
outstanding students, help national rankings and are linked
with better support and funding. From the institution’s

perspective, retention reduces the loss of top performing

students and creates a larger alumni base. Most students
have expectations to succeed and there is a positive
return on investment for the student as well as the
student’s community.1
What We Do Know
The top priority status of health and academic
success comes from Student Affairs and Student Health
professionals. In the Standards of Practice for Health
Promotion in Higher Education, the American College
Health Association (ACHA) has stated that the learning
mission of the institution should be addressed.8 Data
from the ACHA-National College Health Assessment
( ACHA-NCHA) finds that 15% to over 30% of
student’s academics are adversely affected by relationship
difficulties, concern for a family member or friend, or
stress.9 Additionally, the ACHA-NCHA has questions
specifically asking about grades, mental and physical
health concerns and health impediments to learning.
While these are self-reported and not direct measures to
retention, they provide some indicators and suggest
future research directions.
Fu rt h e r m o re, AC H A’s Administration Se c t i o n’s
annual needs assessments typically list interest in re t e n t i o n
as it relates to health and illness. This indicates that
key campus leaders are asking a multitude of units to
demonstrate how their functions support the overall
institutional mission.
Levitz and No e l1 0 listed the following issues associated
with attrition at an Annual National Conference on
Student Retention (noting some as myths):
• Retention will improve without changing our behavior
• Students bring a cogent map of college success to campus
• Retention means lowering standards
• Academic preparedness equates to persistence
• Finances, work, and/or family are the sole reasons students
drop out
• Exit interviews will help shape a retention improvement
effort

As a synopsis of the research on why students

leave higher education, the most common include the
following:11
• Poor academic preparedness
• Low supportive campus climate
• L ow commitment to educational goals and the institution
• Poor social and academic integration
• Lack of financial aid
The literature provides several key health issues that
should be addressed to ensure academic success and
retention. Health behaviors related to alcohol, sleep,
smoking, wake-up times and other negative health behaviors
have been noted. While not casual studies, the following
can be found in the published literature:
• Depressed mood is negatively correlated with academic
performance.12
• Late wake-up times are associated with lower GPAs in
first-year students.13
• There are elevated risks for alcohol-related educational
problems among binge drinkers.14
• Mo re negative health behaviors we re pre valent in midrange
students than high performing nursing students.15
Two studies provide evidence-based views of how
health is associated with academic success and retention
and how each can be improved. DeBerad16 and colleagues
conducted a multiple linear re g ression from a longitudinal
study of academic achievement and retention that included
h e a l t h - related measures. The authors generated an equation
using 10 predictor variables that accounted for 56% of
the variance in academic achieve m e n t .
The authors stated that this equation represents
a substantial improvement over using high school GPA
and SAT scores. Similar to past research, some health and
psychosocial variables (smoking, drinking, health-related
quality of life, social support, and maladaptive coping
strategies) we re related to retention. The authors stated that
this model may be used as a tool to proactively identify
students at high risk for poor academic performance
during their freshman year and to provide direction
regarding proactive intervention strategies for maladaptive

behaviors predictive of poor academic performance (e.g.,

smoking, social support, or coping).
Additionally, they found that coping emerges as a
significant predictor of achievement. Acceptance-focused
coping (blaming oneself for one’s problems lowering effort ,
increasing helplessness) was related to poor academic
p e rformance. Social support was a significant independent
p redictor of academic achievement. Smoking was a
significant predictor of academic performance and
appears related to escape-avoidance coping. From the
Short Form 36 Mental Health Component Summary
(SF-36-MCS) tool, overall level of mental health was a
significant predictor of achievement.
In the second study, Rutgers Un i ve r s i t y1 7 health staff
conducted a health promotion disease pre vention pro g r a m
that had positive effects on health, academic success
and retention. University officials offered economically
d i s a d vantaged first year students thorough physical
examinations, providing treatment when necessary,

health counseling and a six-hour health education class.

The exams revealed primarily social, behavioral and
environmental health problems of anemia, obesity, high
blood pre s s u re and sexually transmitted infections/
diseases (STDs). Additionally, the students had very
poor nutrition.
The intervention resulted in fewer unwanted pre gnancies
and STDs than students not in the intervention.
Of Equal Opportunity Fund Program (EOF) women
students who entered Rutgers before the program was
launched, 7% had unplanned pregnancies compared to
2% who entered Rutgers a year later when the program
was conducted. Likewise, 24% of women and 10% of
men were treated for STDs in the year before the
intervention compared to 8% of women and 6% of men
the following year. The Student Health Services (SHS)
and EOF directors we re able to correlate classro o m
attendance, retention and grade point average to utilization
of health services.

What We Do Not Know

The Center for the Study of College Student
Retention (CSCSR)1 8 p rovides re s e a rchers and practitioners
with a comprehensive resource for finding information
on college student retention and attrition. It publishes
the Journal of College Student Retention: Research, Thyeor
& Practice, has a listserv and a list of literature references
with nearly 150 citations. Unfortunately, only about 10
of the citation titles mention physical, social or mental
health-related concerns. This lack of support in the
literature clearly demonstrates the need for further study.
To support the field, ACHA’s National Health
Ob j e c t i ves Committee developed Healthy Ca m p u s
2010 Mission and Retention Objectives with baselines
and targets (see Figure 1).
While these numbers may provide useful, the
AC H A -NCHA data is at best a proxy measure for this
issue and leaves a significant gap in the literature. If we as
the college health field are going to clearly demonstrate
our role in retention and student success, we must evolve
better measures and publish our findings.
Recommendations to Improve Health,
Academic Success and Retention
In a 1995 presentation, Dennis19 suggests several
keys to success that we can use to support retention of
students. T h ree specific ideas are: get a clear understanding
of the student population, conduct relevant research on
why students leave and persist, and implement effective
interventions. The notable lack of studies and published
evidence-based interventions causes the most prominent
recommendation to be: study the issue and publish. In the
interim, there are some suggestive steps that may help.
The National Association of Student Personnel
Administrators (NASPA)20 has Knowledge Communities
devoted to health, learning and retention. The Health in
Higher Education Knowledge Community provides an
i n s t i t u t i o n a l i zed and ongoing stru c t u re to discuss cre a t i n g
health both on campus and within individuals to advance
student learning and the mission of the unive r s i t y.
N A S PA sponsors the International Assessment & Re t e n t i o n
Conference, with the next conference scheduled for June
2007. The Health Education Leadership and Planning
(HELP) website provides activities, publications, reports,

and documents linking health and learning using the

ecological approach. Among the major resources listed is
the ACHA-NCHA.
We can have a very good picture of our target
audiences by using the standards, resources and tools
p rovided by ACHA and NASPA. Ad d i t i o n a l l y, He l m i n i a k
and Mc Ne i l2 1, in presentations to both AC PA and AC H A ,
offered the following six areas as early steps to addressing
this needed connection between student health and
academic success/retention:
• Re s e a rch and tracking of health behaviors and academic
success measures (GPA, etc.)
• Research linking failure to complete a degree program
and health-related factors
• Including academics in the vision/mission statements
for college health programs (and HP/HE specifically)
• Curriculum infusion health promotion strategies
• Linking health promotion and the general education
goals of the institution
• Including health/healthier communities in the institutional
mission
The presenters acknowledge that without the first
two steps, the field will continue to work in an enviro n m e n t
that asks for answers based on information that does
not exist.
Summary
Student retention and academic success are top
priorities of universities, their colleges/units and students.
There is, unfortunately, little research that succinctly
describes, in terms of health, the student populations that
are academically successful and persist or those that are
unsuccessful and leave. The ACHA-NCHA, plus a few
studies, indicate that health-related problems affecting
academic success and retention are many and varied.
These include smoking, alcohol use, health-related quality
of life, social support, and maladaptive coping strategies.
Studies suggest the development of better assessment and
testing of programs to begin the process of improving
health behaviors, academic performance and retention.
Jim Grizzell, MBA, MA, CHES, FAC H A, is an ACHA
Fellow and Cal Poly Pomona Outstanding Staff and Staff
Emeritus. He was Lead Health Health Educator for Cal
Poly for over 13 years. Among the successful programs and
s e rvices implemented under his supervision was an award

winning 21st Birthday Drinking Social Norms and Tips Birthday

Card, the Study Well Health Assessment, Wellness Card and The
Wellness Center. He was Chair and Co-chair of the National Health
Objectives Task Force which created Healthy Campus 2010. He cu-r
rently teaches online stress management and consumer health courses
for Cal Poly and is a DrPH student at Loma Linda University. He has
been on ACHA committees which developed the National College
Health Assessment, Standards of Practice for Health promotion in
Higher Education and Vision Into Action: Tools for Professional and
Program De velopment. His current position is as the He a l t h
Education/Fitness Program Manager for the US Air Force, Surgeon
General’s Health Promotion Operations office inW ashington, DC. He
can be reached at jvgrizzell@csupomona.edu.
Michael P. McNeil has been involved with college health
since 1993 and has been studying the links between
student health and academics since 2001. He currently
serves as the Senior Health Educator with the Alice!
Health Promotion Program, a unit of Health Services at Columbia
University. Additionally, Mr. McNeil is the Chair-Elect of the ACHA
Health Promotion Section, Secretary of the ACHA A TOD Coalition
and Downstate NY Coordinator for the Bacchus Network. Michael
holds a BA in So c i o l o gy, an MS in Health Education and is curre n t l y
pursuing his doctorate. His past appointments include college health
and adjunct faculty position with schools in Pennsylvania, NewY ork
and Florida. He can be reached at mm3117@columbia.edu or (212)
854-5453.
Notes:
1. Alford, K. and J. Rome. Student RetentionT ool: A Builder's Diary.
Available at http://www.educause.edu/ir/library/pdf/CMR0325.pdf.
2. National Cancer So c i e t y. Pink Book: Making He a l t h
Communication Pro g rams Wo rk. Available at www. c a n c e r. g ov /
pinkbook/page3.
3. Berger, J.B & Lyons, S. (2005). “Past to Present: A Historical Look
at Retention.” In Seldman, A. (Ed.) College Student Retention: Formula
for Student Succes. sPreager Press.
4. U.S. Department of Education, National Center for Education
Statistics. “Sh o rt - Term En rollment in Po s t s e c o n d a ry Ed u c a t i o n :
Student Background and Institutional Differences in Reasons for
Early Departure, 1996–98,” NCES2003–153, by Ellen M. Bradburn.
Project Officer: C. Dennis Carroll. Washington, DC: 2002. Available
at http://www.ed.gov/about/offices/list/ovae/pi/cclo/reten.htm.
5. Wesley R., R. McClanahan. “What works in student retention?”
AC T. Available at www. a c t . o r g / p a t h / p o l i c y / p d f / re t a i n A l l C o l l
e g e s . p d f.
AC T. 2004.
6. Rummel, A., Acton, D., Costello, S., Pielow, G. “Is all retention
good? an empirical study.” Coll Student J, 0146-3934, June 1, 1999,
Vol. 33, Issue 2.
7. Watson, S. Student Success: mI p roving Student Su c c e s s :
Improving Student Retention on Your Campus. 2004. Available at
w w w. e d u c a t i o n a lpolicy.org/pdf/RETENTION_POWERPOINT.pdf.
8. American College Health Association. Standards of Practice for
Health Promotions in Higher Ed u c a t i o n. Ba l t i m o re, MD. ACHA; 2001.
9. American College Health Association, ACHA-NCHA reference
g roup summary, Fall 2005. Available at http://www. a c h a . o r g /
p ro j e c t s _ p ro g r a m s / N C H A _ d o c s / AC H A - N C H A _ Re f e re n c e _
Group_ExecutiveSummary_Fall2005.pdf.
10. Levitz, R., & Noel, L. (1995, July). “The earth-shaking but quiet
revolution in retention management.” Paper presented at the 9th
Annual National Conference on Student Retention in New York.
11. Walters ST, Bennett ME, Noto JV. (2000). “Drinking on campus:
What do we know about reducing alcohol use among college students.”
J Subst Abuse Treat. 2000; 19(3):223-228.
12. Haines ME, Kashy DA, Norris MP. “The effects of depressed
mood on academic performance in college students.” J of Coll Student
Dev. 1996; 37(5):219-526.
13. Trockel MT, Barnes MD, Egget DL. “Health-related variables and
academic performance among first-year college students: Implications
for sleep and other behaviors.” J Am Coll Health.2000;49(3):125-131.
14. Wechsler H, Dowdall GW, Maenner G, Gledhill-Hoyt J, Lee H.
“Changes in binge drinking and related problems among American
college students between 1993 and 1997: Results of the Harvard
School of Public Health College Alcohol Study.” J Am Coll Health.
1998; 47(2):57-68.
15. Poston I, Bowman JM, Rouse JO. “Health behaviors and
academic success.” Nurs Educ.1994;19(2):24-27.
16. De Be r a rd, M. S., Spielmans, G., Julka, D. “Predictors of academic
achievement and retention among college freshmen: a longitudinal
study.” Coll Student J; Mar 2004, Vol. 38 Issue 1, p. 66.
17. Conciatore, J. “Rutgers university uses health services to stimulate
retention.” Black Issues in Higher Education . 1991; 8:11,14.
18. Center for the Study of College Student Retention. Retention
References.Available at http://www.cscsr.org/retention_references.htm.
19. Dennis, M.J. (1995, July). “Developing an effective retention
management system at your institution.” Paper presented at the 9th
Annual National Conference on Student Retention in New York.
20. National Association of Student Personnel Administrators, Events:
International Assessment & Retention Conference. Available at
http://www.naspa.org/events/detail.cfm?id=243.
21. Helminiak, B. & McNeil, M. (2004). “Linking health promotion
with student academic success.” Presented June 2004 at the Annual
Meeting of the American College Health Association.
Suggested Readings:
1. American College Health Association. Healthy Campus 2010:
Making It Happen, Baltimore, MD. ACHA; 2001.
2. Centers for Disease Control. C D Cy n e r gy Social Ma rk e t i n g, version 2.
Available at http://www. c d c . g ov / h e a l t h m a rk e t i n g / c d c y n e r g y / i
ndex.htm.
3. Jensen MA, Peterson TL, Murphy RJ, Emmerling DA.
“ Relationship of health behaviors to alcohol and cigarette use by college
students.” J Coll Student Dev. 1992;33(2):163-170
“ Much of the re s e a rch on why students are not
successful
and leave does not sufficiently provide classifying
resaons and fewer yet investigate health as a factor.”]

“ If we as the college health field are going to clearly

demonstrate ouor l er
we must evo l ve better measures and publish our
findings.”

in retention and student success,

“ Studies suggest the development of better

assessment
and testing of pro g rams to begin the process of
impvr io n g
health behaviors, academic per f o rmance and re t e
n t i o n .”
 Planning for the Transition to Tertiary Study: A Literature Review

Merran Evans (2000)

Introduction
Problems associated with the transition process from secondary school to the first year at
university are not new in Australia see for example Powell (1979) but the issues change with
time. Transition problems can be devastating for individuals and their families, and can result
in enormous social and economic waste (Pargetter 1995). A 1997 study by the Higher
Education Funding Council for England (HEFCE) estimated the direct costs to taxpayers of
higher education non-completion to be about 90 million pounds a year.
Research on student transition, attrition and performance generally and in various discipline
areas and educational institutions, has generally increased in quantity and methodological
complexity in recent years. The findings are not always consistent, and international studies
need to be analysed carefully to ascertain their validity in the current Australian context. As
noted by Clarke et al. (1994), a significant problem related to reviewing the international
literature results from different types of admission policies. Many overseas institutions,
particularly in North America, have an open-door as opposed to the Australian competitive,
and hence selective, admission policy. Another relevant difference is the residential nature of
the institution much of the American research is undertaken in two-year residential (liberal
arts) colleges.
This review focusses primarily on the recent Australian literature and key works from the
plethora of overseas material, and is based on the excellent literature review of Clarke et al.
(1994).

Overview
Research on transition, attrition and performance in tertiary education is extensive, and
research studies and applications based on different theoretical models can be found in the
education, psychology, sociology, statistics and economics literature.
Most of the literature relates to academic performance, which is measured in terms of grades,
pass rates etc., and to persistence or attrition, which are generally (but not always) defined in
terms of voluntary withdrawals, rather than failures or exclusions. Measuring attrition is
difficult and complex and the data obtainable is of variable quality data can include students
'dropping out' temporarily or permanently or transferring to other institutions and can be
affected by external changes.
Transition and attrition research studies are mainly from the USA, but also from the UK,
Canada, Israel, Hong Kong and Australia. Much research since 1975 has been based on
particular theoretical models, such as those of Tinto, Spady, Bean, and on their empirical
validation by Terenzini, Pascarella and others, both generally, and in particular contexts.
In general, these studies suggest that students' persistence and performance are related to
their background characteristics, disposition on entry, goal commitment and experiences after
entry including academic and social integration as well as to external and institutional factors.
Research indicates significant differences in the sources and frequency of difficulties for
different groups of students, depending on
factors such as their academic and social background, and personal and personality
characteristics.
Other factors relate to the nature of the institution its residential character, size, and selection
policies as well as to the type and nature of the course and discipline area. In the USA this
research has resulted in a variety of institutional strategies for selection, orientation,
mentoring, academic and social transition assistance, early contact and community building,
academic involvement and support, monitoring and early warning counselling and advising,
and integration of programs.

Analyses
Early theories on transition were based in psychology, focusing on individual personal
characteristics. From the mid-seventies, the emphasis shifted to sociological factors, and
more recently it has focussed on the institutional context and the students' integration. Tinto
(1993) synthesised much research on the theory of student departure, emphasising the role
of the institution and social/academic integration of students, particularly the interaction
between the students' attributes, skills and dispositions and the institution's academic and
social systems.
Research has been extensive and varied, generally focusing on specific aspects of transition,
persistence and academic performance in particular contexts. Some common themes and
factors emerge from the literature, but variations in findings occur in different countries and
cultures and by discipline, institutions and student categories. Some conflicting results may
also be due to theoretical and methodological issues.
Recent Australian studies include: Calderon (1997) in Victoria, Dobson et al. (1996), Shah and
Burke (1996), Stevens and Walker (1996), Dobson and Sharma (1995), McInnis and James
(1995), Long et al. (1995), Lewis (1994), Clarke et al. (1994), McClelland and Kruger (1993) in
Queensland, Abbot-Chapman et al. (1992) in Tasmania, Everett and Robins (1991), Clark and
Ramsay (1990), Power et al. (1986, 1987) and Linke et al. (1985) in South Australia, Watkins
(1979-1986), Elsworth et al. (1982, 1983).
Studies which focussed on specific discipline areas include: Nursing Burgum et al. (1993);
Medicine Tutton and Wigg (1990); Law Bradsen and Farrington (1986); Education Hart
(1992); Geography Walmsley (1990); Physics Young (1991), Dale and Jennings (1986);
Science Young (1991), Warwick-James (1994); Mathematics Wood and Smith (1993), Watson
(1988); Statistics Smith et al. (1994), Thompson and Smith (1982), Jackson (1997);
Computing Flitman (1997); Accounting Ramsay and Baines (1994), Auyeung and Sands
(1993), Farley and Ramsay (1988); Economics Downes (1976), Dancer and Doran (1990);
Business/Commerce Hand and Fry (1995), Cheng (1991), Stanley and Oliver (1994), Evans
and Farley (1998).
Some studies have focused on study mode or student type: distance education Long (1994),
McMahon (1990); disadvantaged O'Dowd (1996), West (1985); minority groups Price et al.
(1992), Lewis (1994), McJamerson (1992).
Types of comparative analysis include those based on: progress rates Dobson et al.(1996);
chi-squared analyses to regression analysis West et al. (1986), Auyeung and Sands (1993),
Everett and Robbins (1991), McClelland and Kruger (1993), Jackson (1997); neural networks
Flitman (1997); and multilevel statistical modelling Young (1991).
 Factors Identified as Significant
Transition to University study is complex, and varies according to several factors and their
interaction. This is evidenced in the following review, as is the divergence of findings.
Calderon's (1997) recent large-scale Monash comparison of student progress-rates identifies
the stereotypical successful student in terms of personal characteristics such as gender,
socioeconomic status and school background, and shows that these vary by faculty.
Following Clarke et al. (1994), variables identified as relevant in the literature are grouped in
categories.

(i) Student Demographic Characteristics

A variable for age is included in most studies, but the results are mixed, partly due to analytic
problems of definition and control. For example, sometimes analysis includes 'mature age'
students, a variable which often but not necessarily includes students without 'normal entry'
qualifications (see McClelland and Kruger 1993). With increasing alternative entry pathways
to higher education, a variable based on entry type is more appropriate in such cases.
Maturity is suggested as a factor in student success: hence the argument for deferring
university studies for a year after secondary school. Linke et al. (1985) found that 5000
deferring South Australian students generally perceived deferring as 'valuable personal
experience with relevance also to their ability to cope with subsequent studies', but also that
deferment acts as a filter, diverting female non-metropolitan students from entering higher
education. Age appears to have little predictive power in some studies for success (West et al.
1986). However Clark and Ramsay (1990) found age correlated with performance in most
institutions and courses. Shah and Burke's (1996) national Australian study using input-output
analysis found a 20 year old commencing student has the highest probability of completing a
course, and that such probabilities vary with the age of commencement.
With regard to linguistic and cultural backgrounds, Aboriginal and Torres Strait Islander (ATSI)
students have been consistently reported as being less successful (McClelland and Kruger
1993) and less persistent (Abbott-Chapman et al. 1992). Price et al. (1992) studied attrition in
the Northern Territory. Birrell's (1994) Monash study indicates Greek and Asian students have
a high entry and low attrition rate, and discusses the issue of family support and motivation.
Dobson and Sharma (1995) found that generally students in equity groups performed less
well than others nationally.
In some studies gender did not appear to predict performance or persistence (West et al.
1986). However females dominated males in performance in Everett and Robins (1991).
Clarke et al. (1994) considered that the mixed results reported can be attributed to
confounding factors and methods of analysis, and that any interpretation must avoid being
simplistic. Shah and Burke (1996) found that, overall, females have a higher chance of
completing a course, and take less time to complete it, than a male of the same age at
commencement. However, though generally true, the opposite holds in some cases in some
discipline areas e.g. males in Business, Law and Engineering. In general, females have a
higher chance of completion in Architecture, Arts, Education, Health and Science. The pattern
appears less uniform across other ages for other areas. Significant gender differences have
been found in some discipline areas, but others have omitted gender, although it might have
been relevant (Auyeung and Sands 1993). Scott et al.(1996), in a study of mature age female
students with children, found the three major factors for withdrawal were socioeconomic
class, a non traditional major and age.
The North American literature is inconclusive on the relevance of type of school to
persistence. In Australia students from government schools generally appear less likely than
those from non-government schools to enter tertiary education (Elsworth and Day 1983), but
more likely to persist and also to perform (Abbott-Chapman et al. 1992, West et al. 1986),
except in the Tutton and Wigg (1990) study of medical students.
Although the focus here is on school to university transition, special entry is an increasingly
important category in many tertiary institutions. Hitherto this variable was rarely included in
studies because of the small numbers involved. This will change in at least some institutions
with the increasing emphasis on recognition of prior learning and credit transfer, the
expansion of pathways to tertiary education, and lifelong learning. McClelland and Kruger
(1993) in their study of the 1990 Queensland tertiary admissions cohort, found tertiary
performance slightly negatively correlated with tertiary entrance index and performance for a
group of 119 'mature age' students (here indicating a lack of formal qualifications). They also
found that compared with regular school entry students, students with previous post-
secondary qualifications (particularly other tertiary rather than TAFE) were more successful,
but students previously excluded from tertiary institutions less successful.
Relationships between indices of socioeconomic status (SES) and tertiary entry, performance
and persistence are discussed in a comprehensive literature review by O'Dowd (1996).
Higher SES students have been found to have an increased probability of achieving success
(McClelland and Kruger 1993). Most of those withdrawing for financial reasons were from low
SES backgrounds (West et al. 1986), and this is also the case in the UK according to a 1997
report by the Higher Education Funding Council of England (HEFCE). Young (1991) found,
using multilevel analysis, that a composite measure of socioeducational level, parental
occupation and education, and number of books in the home had a significant effect.
Elsworth and Day (1983) found that rural students were more likely to decline tertiary place
offers. This could be related to a financial support factor. A location variable can be a
concomitant of others, such as: socioeconomic status, where home postcode is often used as
an indicator (McClelland and Kruger 1993); financial support (e.g. West et al.1986 found a
significant number of students attributing finance for deciding to withdraw or transfer to an
institution nearer home); and social integration.

(ii) Student Psychological Characteristics

Academic preparedness, and, more particularly, learning strategies and locus of control, were
identified as important in several studies. Significant numbers of students who voluntarily
withdrew from full-time study cited unsatisfactory study skills and a lack of prerequisite
knowledge as reasons (West et al. 1986). The 1997 HEFCE study found a major factors in
non-completion was a lack of preparation and necessary study skills for higher education.
Studying and learning approaches at tertiary level appear to be strongly influenced by
practices at secondary school (Ramsden 1991, Ramsden et al. 1989) and a mismatch may
create problems.
Achievement was found to be best explained by metacognitive ability by Murray-Harvey
(1993) using a cluster of ten variables including age, gender and psychological
characteristics. From the limited relevant literature available, students' performance is clearly
related to their own concepts of their academic ability (Watson 1988 in mathematics). Watkins
(1978-1986) and colleagues focussed on the effects of students' personalities and attitudes,
the nature of institutions and different
faculties, disciplines and learning environments on student learning, study approaches and
adjustment.
Students' goals for tertiary study are an important factor in persistence, having either a direct
or an indirect effect. The influence appears to vary. Students' own goals appear to be
influenced by their perceptions of their parents' attitudes and goals for their tertiary education,
and gender expectations and family background related to student withdrawal. Findings in the
USA indicate that a students' stated intention is a strong predictor, whether of persistence or
dropping out (Astin 1993, Boddy and Neale, 1998). The 1997 HEFCE study found that one of
the most significant factors in UK non-completions was lack of commitment to the course,
particularly among students who applied to higher education because of parental and peer
group pressure. In Australia, the academic orientation and motivation of students has been
found to be a significant predictor of performance and persistence by West et al. (1986),
Abbott-Chapman et al. (1992) and Warwick-James (1994).

(iii) Student Prior Performance

Admission to Australian tertiary institutions on the basis of academic performance is
determined according to one index or some combination of indices, such as secondary school
results or ranking (overall or in specific subjects), the score of some form of scholastic
aptitude test, school recommendations, and other relevant experience or submitted folio of
work. Research, in Australian and overseas, indicates that secondary school subject results
are generally strong direct predictors of tertiary performance.
A tertiary entrance index, using a sometimes complex combination of secondary school and
scholastic results, appears a strong predictor of performance. This is demonstrated in
Auyeung and Sands (1993), McClelland and Kruger (1993), Clark and Ramsay (1990), and
Power et al. (1987) for performance, and for persistence in Abbot-Chapman et al. (1992) and
in the U.S. by Gillespie and Noble (1992). Its validity, however, may decrease over time (Clark
and Ramsay 1990, Schofield 1989). Many studies, including Abbott-Chapman et al. (1992),
Auyeung and Sands (1993), and McClelland and Kruger (1993), found prior academic
performance a strong predictor of persistence, both direct and indirect.
Some studies distinguished between performance in, and undertaking, subjects at school.
Consistently, the predictive power was more obvious for the science disciplines and
decreased in later years (Abbott-Chapman et al. 1992, Auyeung and Sands 1993, McClelland
and Kruger 1993). An early study by Downes (1976) found secondary school performance in
economics and mathematics significant in explaining first year performance in all subjects in
the Economics faculty at Monash, using data from both the mid-60s and 1972, a result
confirmed by Evans and Farley (1998) for the corresponding cohort in 1996 and 1997.
Various measures of scholastic aptitude directly predicted tertiary performance (Everett and
Robins 199l, McClelland and Kruger 1993 (weakly)). Everett and Robins (1991) found the
Australian Scholastic Aptitude Test (ASAT) quantitative test comparable to the total tertiary
admission index in the University of Western Australia for both humanities and science
students.
The rank of final tertiary offer accepted has been shown to directly influence performance
(McClelland and Kruger 1993) and persistence (West et al. 1986) in Australia. Tertiary course
choice has been explored by Kidd (1992) and Kidd and Naylor (1991).
 (iv) Social Factors
West et al. (1986) found family support to be an important factor in persistence for a small
sample of waverers, though a few withdrew because of the difficulty of combining study with
family commitments and needs, and that peer support and relationships directly enhanced
students' persistence. In the UK a major factor in non-completion was that students were
finding it difficult to cope living away from home (HEFCE, 1997).
In terms of study mode, McClelland and Kruger (1993) found no difference in the performance
of part- and full-time enrolled students. Long's (1994) results confirm previous findings that
distance education students are more likely than on-campus students to withdraw, but that
their academic achievement was comparable in later years although marginally lower in first
year.
Withdrawers gave financial problems as the most important reason in West et al. (1986), and
third reason in Abbott-Chapman et al. (1992). The National Board of Employment, Education
and Training (NBEET) (1992) found that financial factors living and course costs for school-
leavers, and insufficient money or lack of student support for adults featured prominently as
factors likely to frustrate applicants intention to undertake their chosen course (with only Year
12 score being perceived as more important). US research supports the view that the
availability of financial aid in the form of long-term loans does not completely remove the
deterrent effect of large tuition fees on low SES individuals an effect which is seen in terms of
access, choice and persistence in higher education (Astin et al. 1980, Astin and Cross 1979,
Carlson 1980, and Stampen 1983). The 1997 HEFCE study found financial hardship as one
of the five main factors in non-completion in the UK.

(v) Institutional Factors

Pascarella et al. (1986) found that persistence in the US was affected by person/environment
fit (which had the most salient influence), measures of academic and social integration (which
had the most direct effect), and student pre-college characteristics (which had the most
indirect effect).
Overseas research has found that 'institutional commitment' is a factor which influences
persistence. Clarke et al. (1994) suggest that, although the perceived goals or vision of the
institution and student/institution fit appear important in some of the literature, on reflection
these factors appear to represent a disparate combination of goals, which are addressed in
other variables such as institutional commitment, personal and social orientation of the
institution, perceived value of the course and course characteristics and faculty contact.
Academic integration, or out-of-class contact with academic staff, has been found to be a
significant predictor of persistence in several U.S. studies such as Gillespie and Noble (1992)
and Tinto (1993). West et al. (1986) found 14% of withdrawers described teaching staff as
uncaring or uninterested.
With regard to social integration, students' perception that academic and administrative staff
provide for their personal and social needs appears to positively influence persistence in U.S.
studies and West et al. (1986). The literature on mentoring has been reviewed by Jacobi
(1991), and Muckert et al. (1996) and Goodlad (1998) quotes international accounts of
student mentoring and tutoring.
The 1997 HEFCE study found that one of the five main factors in non-completion was
incompatibility between the student and the institution students often made the
wrong choice, through insufficient information or had expectations which were not fulfilled.
A mismatch between prior expectations of tertiary courses and actual experiences was found
to be a significant reason for withdrawing by Abbott-Chapman et al. (1992). West et al. (1986),
and Power et al. (1986) found that low commitment and withdrawal were often the result of
inadequate counselling and decision making about university courses. Orientation courses
generally improve retention, and in the U.S. Terenzini et al. (1994) found that faculty
involvement was important in orientation, and that there was a need for parents' involvement.
Other studies include Clark and Ramsay (1990).
A perceived lack of relevance was found to be a significant factor in dropping out in some
Australian studies (Abbott-Chapman et al. 1992, West et al. 1986).
The nature of the course can affect persistence. Findings sometimes vary according to the
discipline area, which can also relate to prerequisite knowledge. Success in science subjects
has been found to be better predicted than in the humanities by the total ASAT test (Everett
and Robins 1991) and by performance in relevant school subjects (McClelland and Kruger
1993). Shah and Burke (1996) found that students have the lowest chance of completing
Engineering courses and the highest for Law once enrolled. The level of student satisfaction
with the teaching and learning activities provided by the institution has been found to predict
persistence by West et al. (1986) (where withdrawers cited little encouragement or
enthusiasm), and by Abbott-Chapman et al. (1992).

Institutional Actions and Planning

While some transition issues will be common to all institutions and groups within each
transition cohort, some are specific to particular institutional environments and student
groups. Transition issues therefore are ultimately best addressed within each institution and
the most effective strategies are those which are mainstreamed within the teaching and
learning environments and in the student support services. A broader analysis of the 'first-year
experience' is required.
Tinto (1993), in his major monograph, wrote that "Knowing that attrition is greatest in first year
does not, in itself, tell us what institutions can do during that year to enhance the likelihood of
persistence and degree completion. For that we have to know about the different types of
leaning which arise at the university and the forces which shape those learnings."
Gillespie and Noble's (1992) US study of 6000 students in five institutions supports Tinto's
view that persistence models are specific to individual institutions and the time period
examined. They discuss the need to identify high-risk students and develop intervention
strategies targeting key factors related to student retention. Other relevant literature includes
Abbot-Chapman et al. (1992), and Terenzini's et al. (1994) suggestions for transition in the US
and the 1997 HECFC study and Yorke (1999) in the UK.
Recent studies in Australasia include Boddy and Neale (1998) and the DETYA study by
Pargetter et al. (1999), which in the final section "Where to now?" identifies a range of
strategies which institutions might consider. The Monash Transition Program, at
http://www.adm.monash.edu.au/transition/ provides information on a range of strategies and
useful links.
This review reveals that certain student groups can be identified as being likely to encounter
transition problems, despite individual variation, and that these will vary according to the
nature of the institution and its student body. Individual institutions will need to identify which
factors are relevant to their students and to plan appropriate strategies.

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