Analysis of the factors related to academic disapproval in the education of nurses: A mixed-method study*

Objective: to evaluate the frequency and factors associated to disapproval among nursing students. Method: a descriptive and cross-sectional study, outlined by the convergent mixed method. A total of 88 nursing students of a Brazilian public university took part. The Reduced Academic Experiences Questionnaire was used for evaluating academic adaptation. The association of the variables in the study with disapproval was verified by bivariate analysis. Results: the frequency of disapprovals in the sample was 68.2%, recurrences in the same discipline in 39.8%, with the associated factors: age over or equal to 22 years old (p=0.015), family income below 2 minimum wages (p=0.019) and lag in the curricular flow (p<0.001). Disciplines with higher frequencies of disapprovals are of the basic area, taught in the first two years of the course and common to the health courses. Students without disapprovals had better perception of physical and psychological well-being (p=0.002), good interpersonal relationships (p=0.017) and more assertive study behaviors (p=0.005). Personal, study-related and institutional issues were motivating. Conclusion: the results reveal a high rate of disapproval, especially in the basic area. An association was found between disapprovals and mental health for nursing students during their education process, and difficulties were pointed out that can culminate with the disapproval rate in the curricular flow.


Method
This is a descriptive and cross-sectional study, delineated by the convergent mixed method, in which the quantitative and qualitative data were collected concomitantly (18) , with associated analysis in the data interpretation stage, starting from the presentation of the results combined from the information obtained in both stages of data collection. The mixed methods approach was used to better understand the disapproval phenomenon, valuing both the generalization of the findings and the depth of the interpretation. Based on the prevalence of academic disapprovals pointed in a recent study with the same theme (13) , the sample calculation was made to estimate the amount of in all the dimensions (α>0.7) (22) .
The instrument has 55 questions in a Likert scale ranging from 1 to 5 and is divided into five dimensions that aim to analyze the following: personal dimension (perceptions of physical and psychological well-being); interpersonal dimension (relationship and establishment of bond with peers); course/career dimension (adaptation to the course and career perspective); study dimension (study skills, habits and time management); and institutional dimension (adaptation to the institution, use of resources provided by it and perception of the quality of services) (21) . The analysis of the qualitative data was carried out by the content analysis modality (23) and, for the elaboration of the categories and thematic axes, the bases of the QVA-r (21) were used as conceptual framework. The sense-related cores expressed during the communication process were identified, being followed the following stages: pre-analysis, exploration of the material, treatment of the results obtained, and interpretation. The analysis procedures were carried out by two researchers in order to mark the follow-up related to the stages and the final result. To designate each speech fragment, preserving the anonymity of the participants, we selected the term "Student", described by the letter "E" ("Estudante" in Portuguese), followed by Arabic numerals according to the order of analyzed answers of the complete questionnaires. in 2016; a distribution that allowed for the analysis of the possibility for disapproval in common or specific core disciplines throughout the course, with more than one third of the sample completing supervised internship (final phase of the course).
Regarding the academic path, it was observed that only 32.5% (n=27) of the sample followed the flow of disciplines suggested by the institution, while a considerable portion was lagging in the curricular flow (67.5%; n=56), emphasizing the pre-requisites locks.
The analysis of the factors associated to disapprovals showed that the age (PR=0.69; CI 95%: 0.50-0.95; X 2 =5.87; p=0.01) and lag in the curricular flow (PR=9.0; CI 95%: 3.09-26.15; X 2 =70.0; p<0.001) variables were predictors, with age less than or equal to 22 years old being a protection factor (Table 1). The frequency of disapprovals per discipline is shown in Table 2. It is important to note that the specific nursing disciplines represent only 14.9% of the reported disapprovals, whose total was 187 in this sample. Thus, the main challenge is contained in the disapprovals in the common core disciplines of the health area. Oliveira-Silva G, Aredes NA, Galdino-Júnior H. The results of QVA-r revealed that the sample has good academic adaptation. The instrument obtained adequate internal consistency in the verification of academic adaptation, both in the dimensions and in the total score, except for the Institutional dimension, which displayed low internal consistency. The independence t test showed that there was no difference in the academic adaptation of students with or without disapprovals. However, in the analysis by dimensions, students without disapprovals obtained better scores in the personal, interpersonal and study dimensions (Table 3).
To better understand the association between disapproval and study the behaviors adopted by the students, the prevalence ratios were checked and were protective behaviors against disapprovals.  Work was also a variable considered in the analysis, representing a matter of subsistence for some students.
In this sense, the full-time course and the need to work represent obstacles for the student to perform both activities successfully. The student's deficit in being able to study autonomously is also highlighted, suggesting the learning difficulty as a strong motivator for disapproval. Some students suggest that this learning difficulty comes from a lagged prior education, which directly implies the lack of theoretical support to accompany the other students.
( The "institutional" category appears in 64.1% (n=34) of the answers, in which there were reports on the methodology adopted by the professor in the discipline and the professor-student relationship. In this aspect, the reinforcement through quantitative data points to the need for better concordance of the teaching-learning processes between professors and students, ensuring that they understand the methods and strategies adopted in the context of nursing education with autonomy and critical thinking. In this way, basing this finding on the weaknesses found in the statistical analysis, they will be able to adopt better behaviors for organizing the information offered in classes (p=0.05) and prepare themselves in a more assertive way for the evaluation stages (p=0.02).

Discussion
Disapproval among nursing students is a complex phenomenon of a multi-factorial nature that implies the risk for academic dropout and to compromise the contingent of qualified nurses available in the labor market (24) . Disapprovals resulting from poor academic performance, important predictors are age, gender, work, critical thinking, and self-efficacy (3) .
In this study, there was a high frequency of disapproval in the sample (68.2%), results higher than in a study (13) with nursing students (5.6%) from Portugal, Italy, Czech Republic, Slovakia and Slovenia and in another study with students from Italy (25) (22.2%). There are still no studies in Brazil that indicate the frequency of disapprovals among nursing students that allow for the comparison of this finding in the country, which highlights the pioneering nature of this study and its importance for future discussions regarding nursing education.
The following factors were mainly associated with disapprovals: age and lag in the curriculum flow provided by the course's pedagogical project. However, it is essential to note that the lag in the curriculum flow is an outcome resulting from the occurrence of disapprovals. Some studies point to age as a predictor of academic performance, suggesting that older students tend to fail less (3,23,(26)(27)(28) ; however, in this study, it was identified that age less than or equal to 22 years old was a protective factor for the occurrence of disapprovals.
In a study carried out in Australia (4) , age older than 23 years was a predictor for low academic performance, corroborating with the findings of this study in the Brazilian Midwest.
Thus, late entry into higher education can be associated with more disapproval, perhaps due to the long interval between the learning practices experienced in high school education and entry into higher education.

Immaturity related to the difficulty in making decisions
regarding study behaviors was a term used in the reports of some students as a possible motivator for disapproval, a finding reinforced by a study conducted in Singapore (28) , suggesting that better academic performance and student maturity are related.

Lag in the curriculum flow was also associated
with the occurrence of disapprovals, but possibly the relationship stems from the fact that disapprovals result in delay in the course and consequent lag in the flow of disciplines.
Unlike the results found in Italy (25) , the comparison of the distribution of disapprovals per student showed that students with a family income above 2 minimum wages have fewer disapprovals in their academic path, suggesting that socioeconomic issues can be important predictors of low academic performance and, consequently, of disapprovals. Considering the change in the profile of those entering Brazilian higher education due to the greater democratization of access, especially in the last decade (1) , psycho-pedagogical support strategies and permanence policies have been adopted with a focus on this target population.
Other studies (13)(14) address the occurrence of disapprovals in the first years of undergraduate nursing.
This period is fundamental for the consolidation of basic knowledge in the health area, generally formatted in disciplines that are a prerequisite for specific nursing.
In the Nursing courses, disciplines such as Pathology, Biochemistry, Physiology, Histology and Anatomy have high disapproval rates (14)(15) , drawing the attention to harm mitigation strategies widely discussed in the universities, such as tutoring and psycho-pedagogical support. In this same sense, the deficit in knowledge arising from previous teaching in conjunction with the number of disciplines offered per period are important impact factors for disapprovals.
All the common core disciplines with reported disapprovals are taught in the first two years of the course, reinforcing that this period is essential to define the path of the nursing student and to predict the time needed to complete the course, increasing as more disapprovals occur. In addition, it is an alert for the monitoring of students, avoiding course drop outs.
In this study, it was observed that disapprovals occur more frequently in the common core disciplines, that is, those that are transversal to all courses in the health area.
Such findings may show difficulty in the transversality of the teaching-learning process and potentially demonstrate the fragmentation of knowledge, considering that the disapproval rate among specific nursing disciplines is significantly lower than in the basic area. However, further studies must be undertaken to identify this relationship and detail the possible variables involved in this phenomenon.
As for academic adaptation, there was no difference between students with or without disapprovals. However, in the personal, interpersonal and study dimensions of QVA-r, students with no disapprovals obtained higher scores. Conceptually, these results suggest that they have a good perception of physical and psychological well-being, good relationships with their classmates, and assertive study behaviors (21) .
These results suggest the need to monitor students who fail, as difficulties in academic adaptation are associated with the occurrence of psychological disorders, such as anxiety and depression, in students from various courses (29) and in nursing students (30) .
The importance is emphasized of psychological issues as motivators of the disapprovals reported by students, since several studies have shown the prevalence of anxiety and depression in nursing students (11,(31)(32)(33) . Therefore, the process of adaptation to higher education impacts both on the academic trajectory and on the mental health of the student (30) .
In addition to the emotional state, the study behaviors reported by the students pointed out that keeping pace with classmates, managing time, keeping up with academic work, setting priorities and preparing effectively for exams constitute protective behaviors against disapprovals. In this sense, psycho-pedagogical support is essential to encourage students to adopt appropriate study behaviors, in addition to developing a greater capacity to deal with psychosomatic issues (34) .
Although no association was identified between the type of basic education and the occurrence of disapprovals, some students perceive the deficit in previous education as a motivator for disapprovals, implying learning difficulty in higher education. The literature has identified the type of school as a predictor of academic success, suggesting that students from technical schools tend to present lower performance (5) .
To this end, Brazilian universities have already devised strategies for strengthening psycho-pedagogical support for students who have learning difficulties (35)(36) .
Likewise, academic tutoring has been shown to be a strong strategy for establishing a bond between professor and student, favoring the sharing of learning and the reduction of difficulties encountered in the educational process (34,37) .
It is noteworthy that strategies to reduce these difficulties, such as the conduction of study groups among students, favor the sharing of knowledge among peers and can provide better performance in undergraduate courses (38) .
Corroborating the findings on study behaviors, the students' reports point to insufficient dedication as associated with the difficulty in establishing study routines and time management. The work variable was not associated with the occurrence of disapprovals; however, based on the reports, it is suggested that in previous situations in which the student needed to reconcile study with work and this caused disapprovals, results corroborated by other authors (13,25) and that need attention from professors and HEI managers regarding the profile of the students and strategies that favor the inclusion of working students in the nursing courses.
The professor-student relationship is a factor that can intervene in academic performance based on the assumption that this interpersonal relationship is part of the process of teaching and learning, of acting at the theoretical-methodological level with the sharing of knowledge, experiences and motivations and guidance at academic level (39) . According to the report from some students, difficulties in this relationship resulted in disapprovals.
Together, the methodology used by the professor in the discipline is a factor that interferes with the students' learning. Active methodologies have positively impacted academic performance and influenced the decrease in the number of disapprovals (40-41) ; however, it is worth mentioning that part of the students presents difficulties in adapting to this pedagogical model, potentially due to a history of education in the traditional model (42) .
In the scientific literature, there are highlights for characteristics that strengthen student satisfaction and good academic performance, namely: professor qualification, application of participatory teaching methodologies, updated didactics and insertion of the students in the practice environment, making them to be the protagonists of their learning process (43) . In addition, the curricular restructuring of the course is also important to provide the student with learning tools (44)(45) to complete the course on time (1) and with appropriate Oliveira-Silva G, Aredes NA, Galdino-Júnior H.
educational support (13) , especially for students with learning difficulties.
In this sense, the opportunity to create integrated curricula for the education of nurses with clinical reasoning, critical thinking, and leadership skills with a focus on advanced nursing practice is seen in curriculum restructuring (46) , in view of its importance for individual and social transformation based on the active participation of the users of the Unified Health System (Sistema Único de Saúde, SUS) (47) and possible future implementation in the national context (48) .
Given the undeniable need for nurses to be available in the labor market, especially associated with the excess and complexity of demands in the health services (49) ,

Conclusion
In this study, a high frequency of disapprovals was observed among nursing students, with students aged representing a dropout risk before the student gets to know the course better.
There was no difference in academic adaptation between students with or without failing; however, students without disapprovals had a better perception of physical and psychological well-being, good interpersonal relationships with peers, and assertive study behaviors.
Keeping pace with classmates, good time management, keeping up with academic work, setting priorities, and having effective preparation for exams were protective behaviors against disapprovals.
As for the factors that motivate disapprovals, from the perspective of the participants, issues of a personal nature were pointed out: immaturity, the fact of reconciling study with work, and psychosomatic problems; issues related to study: learning difficulties, insufficient dedication, and difficulty in managing time; and institutional issues: professor-student relationship, methodology adopted by the professor in the discipline, and curricular structure.