Beyond enrolments: a systematic review exploring the factors affecting the retention of Aboriginal and Torres Strait Islander health students in the tertiary education system

A range of personal support networks were pivotal to students’ well-being and to their remaining at university. Family support was the most frequently mentioned enabler for retention [20, 28, 43, 46, 47, 50‐53, 60] with family providing support, even when they hadn’t had educational opportunities themselves. Family support included emotional, financial and physical support, including when students were far away geographically, and it gave participants the confidence to go to university and encouraged them to remain there. Peer support from fellow Indigenous students, particularly those studying a health course, was also very important [28, 46, 48, 50‐52, 60]. The value of support from workplaces and professional networks such as the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) and the Australian Indigenous Doctors’ Association (AIDA) was also identified [44, 47, 50‐52]. While not necessarily part of students’ support networks, senior Indigenous students and graduates of the course were inspiring and highly motivating role models for students, helping to engender confidence in their studies and encouraging them to stay at university [20, 46, 47, 52]. Conversely, where there was a lack of support or understanding from family or workplace, this contributed to students’ feelings of stress, isolation and loneliness [43, 45, 47, 50].

Internal motivations were a powerful driver for many students, with wanting to make a difference for Indigenous health the most frequently mentioned [28, 44, 45, 50, 52, 53]. Students also reported a desire to be a role model and inspire others within their family and community [50, 52, 53], and to improve their career options and “have a more influential role in [health] policy making” [45, 50, 53] as motivators for continuing with their studies.

A number of personal attributes were identified in the literature as having a protective effect; confidence, resilience and perseverance were all influential on course completion [46, 48, 51‐53]. Some mature aged students reported feeling confidence as a result of their life experiences (previous employment, parenthood, positive educational experiences) and the skills they had acquired (such as study skills, communication, teamwork) [28, 46, 48, 51]. West et al. [28, 52] found that student nurses’ ability and willingness to seek out and then accept support was pivotal to successful course completion.

Having competing obligations was the most frequently mentioned barrier to remaining at university, reported by almost half of the included articles [20, 44‐48, 50‐52, 54, 57, 60]. Competing obligations included difficulties meeting family and community commitments, stress caused by family crises or illness, and difficulties balancing study, work and family. Financial hardship was mentioned by a quarter of articles as a reason for not continuing with study [20, 43, 45‐47, 51, 60], and in some instances was exacerbated by feelings of shame for seeking financial assistance from others. Usher et al. [51] suggested that students’ financial burden had a cultural component as participants reported that they were expected to share money with extended family members, an expectation not usually experienced by non-Indigenous students.

Students described a range of cultural and academic support strategies implemented by schools and faculties that helped them continue their studies. Cultural support included supportive non-Indigenous academics and clinicians [28, 43, 50‐52] who helped students to feel safe and comfortable at university. Support from Indigenous academics and clinicians was reported by students in three studies as “essential” to their remaining at university [28, 50, 52]. Culturally inclusive teaching and learning practices with consideration of different student learning styles, as well as embedding Indigenous content into the curriculum, was reported as assisting retention by students in four studies [28, 51, 52, 63].

Racism and discrimination were barriers reported in over a quarter of included studies [43, 46, 47, 50‐52, 64], with West et al. [52] describing racism and discrimination as “one of the most pervasive and debilitating barriers to successful course completion” (p. 353). Examples ranged from questioning the student’s Indigeneity, to discrimination and a lack of acceptance by students and staff because the student was viewed as receiving ‘special treatment’.

Schools or faculties could support students academically by being flexible in their delivery of course content and allowing students to move between study modes (internal/external, full-time/part-time) [28, 51, 54]. This was reported as enabling individuals to modify their mode of study according to personal needs, allowing them to “hang-in there” ([54], p. 40). Access to tutors [52, 54, 63] and mentoring [63, 64] helped create a safe, supportive space for students.

The Indigenous Student Support Centre was reported by participants in a third of articles [20, 28, 43, 44, 46, 47, 50‐52] as providing academic, social, emotional and cultural support, including tutoring, and advice on finances, scholarships and accommodation. Receiving financial assistance such as a scholarship, cadetship, or ABSTUDY (special government benefits for Indigenous students in an approved course of study), helped students to remain with their studies, especially during clinical placements when they generally had to take leave from their paid employment [43, 50‐52, 54, 63].

During the recruitment and preparation stages, students reported that recognition of their existing skills and prior learning helped them feel “empowered” and valued; when course exemptions were granted, this contributed to improved retention by helping students complete their degree faster and reducing financial pressures [50, 63]. Comprehensive orientation programs helped students to understand school or faculty expectations, meet other students and feel accepted and welcomed by staff [46, 51]. Conversely, a challenging admission process, such as a lack of formal pathways from vocational education and training (VET) courses that articulated with university studies, or difficulties applying for recognition of prior learning (particularly for Indigenous Health Workers), contributed to students feeling stressed, disempowered and undervalued [20, 50, 60, 64].

Multiple articles, predominantly those looking at strategies implemented in medical schools, claimed that retention starts with appropriate selection [58‐60, 64]. Medical schools aimed to select students who would successfully complete the course by looking at applicants’ motivations, support structures and ability to balance study with other commitments. Lawson et al. [59], in their discussion of the strategies adopted by the three leading universities regarding Indigenous student enrolment in medicine, reported a strong link between selection and retention, although they acknowledged the need to achieve a balance between achieving a high completion rate and giving “higher-risk” students a chance. Two articles emphasised the importance of selecting students through a culturally appropriate interview process [60, 64]. The importance of offering multiple pathways into medicine was also stressed [58, 59, 61, 64].

Three studies identified the importance of a cohort effect with Indigenous students enabling peer learning and support [46, 58, 60], while others identified the importance of course quotas with specific places available for Indigenous students [11, 59]. Being with other Indigenous students directly benefitted students’ academic success and likelihood of retention, reflecting the moral and academic support students can provide to one another. For example, Meiklejohn et al. [60] concluded (p. 7):

"A critical mass of eight students has been identified as the minimum number of enrolees at any one time likely to result in successful completion of studies. Numbers of less than eight may leave students feeling isolated, and without study partners, encouragement and peer support."

Articles described pre-entry preparation programs and comprehensive orientation programs as an effective way to inform students about the support available to them at university, as well as communicating university expectations and managing student expectations. Descriptions of pre-entry preparation programs were relatively common [54, 56, 58, 59, 61, 64], although predominately employed by medical schools. Courses described as “pre-entry” varied substantially in terms of the aims, content covered and duration, with examples ranging from 5 days to 1 year. Holliday et al. [58] described a comprehensive 5 day pre-entry to medicine intensive course which demonstrated positive outcomes, including 100% retention rate during first year for participants of the program, and “overwhelmingly” positive feedback from students. Comprehensive orientation programs were less commonly described [34, 46, 58] and ranged from 1 day to 2 weeks in duration. As one component of the Indigenous Nursing Support (INS) model: Helping Hands, Best et al. [34] described an orientation tool developed for Indigenous student nurses, which included the ‘Dandiiri’ orientation breakfast, a special enrolments area and formally allocated staff support.

Providing cultural support for Indigenous students was recognised as needing to come “from the top”, with over a quarter of the articles reporting strong organisational leadership and a deliberate attempt to foster an enabling culture within their schools or faculties [28, 34, 55‐57, 59, 64]. Leadership at the institutional and faculty or school level had flow-on effects within the organisational hierarchy, creating an enabling culture which incorporated Indigenous knowledge and sought to support and respect the Indigenous identity of students. Fostering cultural safety required commitment from every academic rather than relying on one or two motivated staff or only Indigenous staff.

Schools and faculties also demonstrated a commitment to cultural safety by implementing cultural awareness training for non-Indigenous academics and students [11, 55, 56, 64]. However, a review co-authored by the Medical Deans Australia and New Zealand (Medical Deans) and AIDA [64] found that these programs were generally targeted towards students rather than staff, that attendance was voluntary and they were often viewed as being “tokenistic and counterproductive” (p. 35). Specific strategies to address racism were only reported in two articles [59, 60]. Meiklejohn et al. [60] briefly described a number of implemented strategies to address racism including offering counselling and ongoing support to the victims, an address by the Head of School to the student body and disciplinary action taken against the perpetrators, however, there was no indication of how successful these strategies were. Stuart et al. [50] recommended implementing a formal complaint process (including an anonymous hotline number) and employing Indigenous counsellors to give advice to staff and students as a response to the racism commonly experienced by the participants in their study.

Indigenous academics supported students culturally and academically [28, 34, 44, 49, 50, 62] with regular contact helping students stay connected and focused on their studies. Schulz et al. [49] describes how the new Indigenous Academic Liaison Midwife (IALM) was respected by students “as a culturally appropriate professional role model” who advocated for students with the other academics, with one student stating “if it wasn’t for [the IALM] I wouldn’t have made it this far” (p. 62). Also supporting students culturally and academically was the inclusion of Indigenous content in the core health curriculum [34, 55, 56, 61, 64], which made the curriculum more relevant for Indigenous students (increasing the likelihood of retention) and reinforced the belief that Indigenous health issues were worthy of discussion [34, 56]. Two articles described how Indigenous content was developed in consultation with local Indigenous people to ensure that materials were respectful and safe [55, 64]. None of the articles described the exact nature of the Indigenous content, only that it “foregrounds Indigenous world views, cultures and experiences” ([56] p. 131), although an audit of the curriculum of all Australian medical schools by Medical Deans et al. [64] found that Indigenous health content covered a wide range of topics including “rural Indigenous health, cultural awareness and cultural implications for health, Indigenous history, communication, clinical presentations of disease, population health and social determinants of health” (p. 12). The amount of Indigenous content incorporated into the curriculum varied amongst the five articles and ranged from one core undergraduate unit [34, 55] to a combination of core units and electives throughout the course [56, 61], to Indigenous health not being taught discretely but as “integrated components of broader subject areas” ([64] p. 12). Schools and faculties reported involving the local community through service programs, clinical placements at the local Aboriginal Medical Service, and talks from Elders and local community members [34, 55, 56, 62].

The two most commonly described strategies to provide academic support were targeted mentoring programs [11, 34, 48, 57‐59, 62, 64] and tutoring [11, 34, 46, 58‐62]. Mills et al. [48] described the implementation of mentoring circles (a form of group mentoring) as a successful way to support Indigenous nursing students during their studies by empowering them to develop the skills they identified as needing to complete their studies. The review by Medical Deans et al. [64] described a mentoring program where social and academic support and professional guidance was provided by experienced (non-Indigenous) clinicians, with some students regarding the mentors as “akin to Elders” (p. 33). Four articles briefly described strategies to support nursing students during clinical placement [34, 49, 53, 57]. Best et al. [34] mentions the “Coolamon clinical school” as a service that provides “support with clinical nursing placements for all Indigenous nursing students” although the exact nature of that support was not specified (p. 64).

Flexibility in the delivery of course content was another way to support students academically [11, 46, 49, 56, 57, 60, 62]. Some schools or faculties aimed to reduce the travel burden to students by delivering the course in block mode, and Hinton et al. [57] described a Bachelor of Nursing timetable that specifically focused on reducing any impact to family commitments while maximising clinical placement and lab time. Both Meiklejohn et al. [60] and Farrington et al. [46] described how students could choose to reduce their study load, while concurrently completing tutoring or an Aboriginal health science support program, with participants in Farrington’s study reflecting that they would not have coped with a full load.

The two most commonly described strategies to provide social and economic support were financial support [11, 57, 59‐61] and fostering peer networks [34, 48, 55, 60]. Descriptions of financial support included: assistance applying for scholarships and cadetships; access to class sets of text books, laptops, diagnostic kits; and funding to attend conferences or a travel allowance during clinical placements. Schools supported and encouraged Indigenous students to network by organising social events such as breakfasts and morning teas as an informal way for students to meet. No articles reported on strategies to encourage networking between Indigenous and non-Indigenous students, although Harris et al. [56] described a planned buddy system that would encourage Indigenous and non-Indigenous students to work together to “provide first-hand experience of reconciliation in action, and important exposure to perspective taking” (p. 133). A small number of articles described ‘personal contact’ as a strategy for retaining students [34, 60, 64], with feedback from students in one study indicating that this was “critical to success” ([64], p. 33).

Only Best et al. [34] mentioned the importance of celebrating graduation, with the inclusion of a graduation tool within the INS model: Helping Hands to help nursing students celebrate their success. However, Harris et al. [56] described how progress was recognised throughout a Graduate Diploma in Psychology program, by providing a certificate after the first year was completed and a diploma at the end of second year. This had the added advantage of providing “exit points” throughout the qualification. Harris et al. [56] explains (p. 133):

“The reality is that not all students will make it through a 3- or 4-year degree. For many students who are the first generation of their family to attend university, a certificate or diploma recognising what they have done is an accomplishment. It provides a way to exit without losing face, and hopefully encourages them to come back, or, to pursue some other tertiary qualification. It also signals to an employer that the student has attempted tertiary training in psychology.”

The importance of “leaving the university door open” for students who left before graduation, was also mentioned in two other articles [59, 60]. Strategies to prevent students withdrawing unnecessarily included offering a leave of absence when a student’s progress stalled due to outside factors, and the option of transferring to a less onerous course of study for a year if the student is struggling academically.