The (dis)integration of nursing students. Multiple transitions, fragmented integration and implications for retention

There are widespread concerns about a shortage of nurses in society, making it vital to educate and retain as many nursing students as possible. This paper interrogates the fit and relevance of established models for student retention, particularly Tinto’s model of student departure and its central notion of ‘integration’. Early social and academic integration of students is generally important to promote persistence and prevent early departure. We consider how integration plays out in degrees with extensive practice placements in clinical settings and large degree programme cohorts, investigating the challenges for persistence. Additionally, we question how well Tinto’s understanding of integration fits with the structure and format of the nursing programme. Building on comparative interviews with 2nd and 3rd year nursing students in Norway and England, we argue that common understandings about how students are integrated into degree programmes are unlikely to fit the case of nursing. As this programme takes place at multiple sites, the integration process is often experienced as fragmented or interrupted. We find many nursing students describe a prolonged liminal state of disrupted integration, posing challenges for motivation, and greater risk of leaving. We suggest this is driven by shifts between practice and academic sites, combined with institutional practices which encourage frequent changes of peer group, physical location and academic network, all of which interrupt integration processes. Finally, the paper offers suggestions of institutional scope to promote integration within nursing degrees.


Introduction
Several studies have shown that being well integrated into one's higher education (HE) study programme is important for students to thrive and to be supported or encouraged to complete their studies (Braxton, 2000, Seidman, 2005, Tinto, 1993. The aim of the paper is to investigate nursing degrees from this perspective. Educating enough nurses is a general concern across Europe, given an aging population and needs for workers with nursing qualifications, and it is therefore essential that students who are recruited to nursing programmes are enabled to also complete their studies and qualify as nurses. This paper draws on dominant models used to study and improve student retention, notably Tinto's (1975Tinto's ( , 1993 model. It interrogates the fit and relevance of the model for nursing programmes, focusing on its central notion of 'integration'. The importance of integration, particularly early integration into the programme and the institution, is a common focus and finding in research on dropout and completion in HE. Tinto's (1993) argument is that students who integrate early and well -both academically and socially -are less likely to leave the programme. We re-examine assumptions from more 'generic' HE retention and dropout literature, and assess how far these perspectives can and cannot apply in the case of nursing (or other professional degrees), and describe and develop recommendations specific to nursing programmes. This is important, as differences in degree structure, and professional regulation of these degrees, leaves institutions limited scope to change course features or content. Within these quite complicated and complex degree structures, we aim to identify key barriers to retention or completion, risk factors for dropout and identify how institutions might improve and support students' experiences.
The research questions addressed are: 1. How do nursing students experience academic and social integration in their programme? 2. What factors inhibit and support their sense of integration? 3. What are the implications of this for theories and assumptions in retention research and institutional practices?
Theoretical framework Tinto's (1975Tinto's ( , 1993 model of student departure is widely recognised and applied in literature on student retention and dropout (for examples see Braxton, 2000;Urwin et al., 2010;Crombie et al., 2013;Mooring, 2016). The model has several key traits: it sees drop out as the outcome of a multi-factor process, and its central focus is on what happens while the student is at the institution. Key concepts in the model are 'integration' and 'commitment', and in this paper we are focusing on disentangling the first concept, integration, marked with a circle in Fig. 1. Tinto describes the importance of integration in these terms: "experiences serve to integrate individuals into the social and intellectual life of the institution… the more satisfying those experiences are felt to be, the more likely are individuals to persist until degree completion" (Tinto, 1993:50). Hence, this illustrates the emphasis on students feeling connected to their institution to drive completion. However, Tinto's model is built around traditional university degrees, which assumes integration 'into' a single academic environment and a single community of peers (and teachers), which usually happens early in the programme. Our understanding of integration is wider and linked not only to the institution but rather to students' feeling of being integrated into multiple communities spanning teaching, learning and engagement in both academic and practice settings.
To explore these issues in nursing degrees it is important to unpack and re-examine the concept of integration, as nursing differs from regular academic degrees in involving both academic and practice elements. While nursing training was originally practice-based within hospitals, it is now an academic, degree-level qualification, co-delivered within an HE institution and practice-settings. EU-regulation dictates what kinds of practice placements nursing students should have and the length of these placements, 1 and this is required to be licensed to practice as a nurse. Placements are therefore key sites, in addition to the HE-institution, for reinforcing or weakening social and academic integration.
Nursing students face demands to acquire and demonstrate both disciplinary and practical knowledge, which requires reflexive work to link these two types of learning and construct an identity around them (see Smeby & Sutphen, 2014). It seems possible that the structure of the programme, with the combination of university courses and practice placements in different healthcare contexts, is likely to lead to differing integration experiences for students than those typically described in undergraduate degrees. Several earlier studies on nursing degrees have focused on challenges students may face during their practice placements (see for example Clipper & Cherry, 2015;Wakefield, 2018).
The literature around student retention seems to offer two main perspectives on the nature of integration processes, divided into linear and non-linear models of integration (Weidman, 2006;Weidman et al., 2001). Linear models of integration, including Tintobased and other retention models, imply a uni-directional model of socialisation and degree progression. These models see incoming students as having and being selected for certain criteria, arriving at a specific and singular academic environment where they gradually develop a 'match' or socialisation between the individuals' habits, academic level and programme setting and the academic environment. Grade performance and belonging, both central to Tinto's work, are assumed to develop steadily over time, with the integration process continuing to completion, or stalling and leading to dropout. Weidman et al. (2001) refer to such linear models as representing the 'standard plan' for HE socialisation.
However, in professional degrees there are often alternative, non-linear models, at work, based on loops of socialisation with communities both internal to and external to the university (Weidman et al., 2001). Whereas issues of social integration are often seen as something of a 'side issue' or a non-essential feature in comparison to academic integration in linear models, in the non-linear models the focus on reflection and multiple communities tends to portray the academic and social elements as more entangled. Hence, these models  (Tinto, 1987(Tinto, , 1993, with the process of integration in focus highlight that in professional and post-graduate training, students typically have several communities to socialise into: internal academic ones as well as external professional ones. Getting integrated into several communities at once might be much more demanding and time-consuming than integrating into a single context.

Data
To investigate how integration is experienced in relation to the specific case of nursing programmes, we use interview data with nursing students in Norway and England. The English interviews were conducted in 2016, while the Norwegian interviews were conducted in 2019-2020. All interviews were conducted using the same interview guide, and the two groups of interviewees were largely similar in terms of demographic characteristics. In both countries, to make sure that all interviewees had experienced at least one of the practice placements during their studies, all students had studied for a while. Norwegian students were in their second or third year of study (marked in quotes), while English students were in their last year when recruited. 2 The English data set consists of 70 interviews from 10 different sites, while the Norwegian data set consist of 30 interviews from three sites. All the English interviews were conducted individually. Most of the Norwegian interviews were individual, a few were conducted in pairs where respondents preferred a joint interview with a peer from their programme. Almost all interviews were conducted faceto-face, however, some Norwegian interviews conducted in spring of 2020 were conducted via Teams (due to the Covid19-pandemic). There was no obvious difference in depth or quality of the interviews conducted digitally, and as such the pandemic had not had any direct consequences for the project. All interviews are transcribed, and initial analysis was done using NVivo.
In the English data, having a 'diversity characteristic' (being of the underrepresented gender (male), of mature age, first-generation HE-student, or having a disability/illness) was one of the selection criteria for participation in the study. In the Norwegian data, diversity was not explicitly part of recruitment, although efforts were made to recruit male nursing students as a minority within the programme. The two national study programmes are quite similar in their recruitment patterns, as nursing programmes in both countries tend to recruit mainly female students (10% or less of students are male). Compared to traditional university students, nursing students are more often of mature age and from families without prior HE-experience (see Pryjmachuk et al (2019) for England, and Helland and Hovdhaugen (2021) for Norway). This higher share of mature students also implies that significant numbers of students will have children and family responsibilities. There are also some differences between the two countries. One of the largest is funding. Nursing education in England used to be a government funded programme (up until 2016), via a governmental allowance or stipend. This system is now abolished and English nursing students, like their Norwegian counterparts, typically get student loans to support themselves while taking a degree.
Having data collected in a similar way, from two different European countries, allows us to test how far patterns found are unique to one country or more general to nursing degrees.
The analysis drew on the interview guide structure, which covered the students' experiences of choice of course and starting their degree, range of experiences so far within it, and their plans for the future. The issue of integration was explored in a relatively openended way in the empirical material: questions about students' experience starting the programme, what they had found challenging and what had helped them overcome the issues raised. Additionally, questions about students' plans to complete and go on to practice all provided a great deal of material relevant to integration as a nursing student. The analyses were shaped by the focus on the concept of integration (and commitment), but the primary aim of thematic coding and pattern building was to capture the student experience, rather than fit within Tinto concepts.

Findings -integration into a nursing degree
In this section we present key findings and patterns on integration for nursing students, to aim to clarify: to what extent are nursing students able to integrate into their programme; and which factors inhibit and support integration? Implications for institutional practices, and retention theory are addressed in the discussion section.

Similar initial integration challenges
As in many other HE-programmes, nursing students describe the basic process of adjusting to the academic process within their HE institution as initially challenging. Many must adjust to a new city and institution with academic and personal challenges: new subjects, greater complexity and depth and learning to take responsibility and study independently, as well as living away from home and needing to make new friends. Many of the students, especially those in Norway, note the scale of the programme and feeling anonymous in large cohorts where they are yet to meet many people.
I moved here two weeks before school started so for me it was a completely new city, everything was new to me then. It took extra time to get used to everything in the city and then the school was completely different than high school. There you sat in a classroom, but here we were too many students, we were 600 students in our class. The lecture hall was very full you just sit and listen. You do not get that much input and if you miss something then it was lost.... It took a while to get used to it, maybe after 1 month, I was getting used to the way they taught, it was a bit difficult. (Norway, female, year3, inst1) Many feel the academic level required of them is higher than expected; students found the early courses involved large volumes of material, which was academically challenging. Few of the nursing students in Norway and England see themselves as very academic, which can present a challenge to their confidence and sense of being suited to the programme. Even those who see themselves as academically strong often comment on the workload and the academic level being high, and on the pressure to pass all exams the first time, to avoid complex re-sit processes. This is illustrated by students from both countries: No-one realises how challenging it is going to be when you go in as a first year. Then you realise it is harder than you thought, doing research and lots of literature reviews. (England, female, inst5) I know a lot of people are shocked by how demanding it is, how high a score you need to pass an exam for example. The fact that you were a quite good student at high school does not necessarily mean that you will get top grades at college. (Norway, female, year3, inst2) Students experience these academic challenges (common to many students entering HE), but they also feel the sense of responsibility embedded in studying to be a nurse. Despite anticipating a degree that expects a lot of them, it is a demanding transition, to feel the 'reality' of the role, and the responsibility entailed.
It is demanding. But it was also one of the reasons why I chose nursing, that I want it to be challenging, and exciting and rewarding and meaningful… it's like rescuing people in the most vulnerable, who are somehow dependent on us. And helping someone in need then, it makes sense. And when you become a professional in the end then, it becomes a part of your life as well, so then it will affect me that you work with something that is meaningful then. (Norway,female,year2,inst1) This points to the intensity and challenges as a potential a motivator for students, that once they have started transitioning into the programme, they see the demanding academic work in the course in a more positive way, but only when they feel they will be able to meet this challenge over time. However, the Norwegian students particularly described the intensity of the first year, and the feelings of uncertainty and disorientation, as a more negative or undermining challenge. Some see this phase as a 'test', or a period deliberately devised to see who 'has what it takes', and therefore one where a reasonably high number dropping out or not returning in the second year is to be expected or even desirable.
I felt in a way that the attitude [from the nursing programme] was a bit that, and there was someone, a teacher who sort of mentioned it, that it [the 1 st year] is a bit made to test which of you is suitable. (Norway, female, year2, inst1) I only know one person who has quit, but I think we were like 700 students when we started, and about 200 have quit. A lot leave after the first practice period. Maybe they find out it's not for them, because it's a nursing homes and there is a lot of personal care… Body fluids and all that. It's a reality that you may not have been fully prepared for. And then it's good to find out the first year. (Norway,female,year3,inst1) This sense of the first semester, or first year, as a test of perseverance and personal fit is daunting for some students, especially when combined with a widespread sense of being feeling anonymous and adrift within a very large degree programme. Several Norwegian students, particularly those at larger institutions, describe a very weak sense of peer group, or lack of academic mentors or teachers they can turn to for support. In England, students seem to feel less concerned by being anonymous in their programme, possibly because they expect the degree programme to be large and intensive. Nonetheless, the first year being a tough and expectation-raising experience is a reoccurring theme in both countries.

Multiple spheres of integration
One of the factors nursing students attribute a weak sense of integration to, is the organisation of programmes where they must constantly participate in new settings with new people. As the nursing degree is built on a combination of academic courses at the institution and practice placements at different sites, students describe a feeling of never getting to settle in and experience stability in their environment and peer group. Our analyses suggest this is due to two dynamics which are different in nursing, compared to standard undergraduate degrees. The first is that nursing degrees involve integration into not one but multiple social 'spheres' and contexts: they have parallel challenges in integrating into the academic sphere and the practice sphere. As they are constantly shift between these two spheres, typically with new peers in every new setting, they may struggle socially, as they never become completely integrated at the institution. The second factor is that common organisational approaches and institutional attitudes often act to disrupt integration dynamics. These factors contribute to a feeling among many students of being in an extended transition period, or a set of transition periods which follow one after the other. This continued sense of newness and transition does not facilitate integration, as students feel like they have to start over again, with getting to know their academic peers or placement colleagues.
The combination of academic courses, practice placements and assessment creates a hasty pace. Students' sense of confidence that they are acquiring and consolidating the knowledge needed for professional practice is often challenged by feeling rushed, compounded by course fragmentation and a sense that they are just 'scraping through' each stage, and on to the next.
Balancing assessments and placement, because I've felt like we've not always had enough time to do both and some of the deadlines have been unrealistic, with the amount of shifts that we've been doing and having an exam in the middle of a community placement, I felt was really not appropriate. (England, female, inst11) There's often a lot at once. It is rare that there is any breathing room between practice and exams, for example. I experienced many times that you finish your 8 weeks practice, then you have to take an exam a couple of days afterwards. You become quite exhausted. (Norway, female, year3, inst2) These quotes points to nursing students in England and Norway describing the programme as a constant shift between being academic and placement learning, with no 'room to catch one's breath'. This pace of the programme can work against students being properly integrated, as they barely have time to gain a sense of accomplishment or reflect on what they have learnt. Instead, they constantly under-prepared, slightly behind and just scraping through. For some students, the rapid shift between academic and practice settings also creates a sense of inconsistency and that their learning is not aligned with practice and feels incoherent. Plus, there is a disconnect between theory and practice, for example, elements of patient care seem unrealistic in practice.
So much of the nursing literature is very idealistic. And that was something I felt in the first practice period… I think they prepared us too little for that -maybe just because there's such a squeeze on time. (Norway,male,year3,inst3) This again points to the challenge of operating in multiple spheres across the programme, and not just at the HE site. In practice placements students' experiences can vary considerably, and they are often facing these situations without the support of a peer group, or supportive colleagues.

The role of peers and friendships
Another challenge which seems to persist social engagement in general and course peers in particular. In each new setting, students encounter a new peer group; they would like to get to know their peers in more consistent, smaller groups.
It's just so unstable for us students, because we must get to know new people all the time and they [the university] just say "yeah, yeah, that's part of the job". They say they understand that it is annoying for us, but that it is part of the profession, to get to know new people and collaborate with others, even if you do not like them or even if you do not get to know each other. That's one of their arguments. They understand it does not work that well. And it's exactly the same with the study groups, there are new groups every year. (Norway, female, year3, inst1) This particular student came from a large institution, with several hundred students in a cohort. In Norway, students in smaller programmes seem to be more satisfied and integrated. Students were better able to engage with peers and get established in smaller programmes; this was also true in some large cohorts were the university made a purposeful effort to provide stability through consistent 'study groups' throughout the first year. In the English context students were more focused on the fact that their institution usually was located away from the main campus, which contributed to making it more difficult for students to integrate with non-nursing student peers.
I feel that we've not been integrated enough into the university side of it, because the main campus I quite far away and we are an isolated group. (England, female, inst8). Socialisation was further hampered by shift working, and for mature students, juggling family commitments with studying, placements and working. Several interviewees indicated that they has found one or two good friends among their degree programme peers early on, and this was central to helping them overcome challenges and maintain perspective during the 'normal' stresses and strains of studying, and avoided them concluding they were 'not cut out' for nursing or academic study.
The importance academic and social integration is reinforced by the number of students who focus on the contribution of course peers, family and other friends in supporting them through their degree, rather than official institutional support. For example, in response to the question: "What stopped you from leaving?" this respondent said: My family, definitely. My eldest son, bless him, he's only thirteen but he's so patient and he's always saying, 'You need to do this.' My family are just encouraging, and my friends. It is literally just the peer group that I have, that everybody feels the same. (England, female, Inst1) S1: I think it is very natural for people to want to belong to a group -that you feel you have a place you belong to, there is someone you know well, that you feel safe and that you can have mental support so that you know that you have someone there cheering you on. S2: That you get help if you are struggling. I think many people can feel a little lonely. I think that not feeling lonely and that you know those you are alongside has a very positive effect on how you feel. (Norway, 2 female students, year3, Inst1) As mentioned, some students express that they found 'their little group of friends' early on, which offered excellent support. Students describe relying on peers to discuss and reflect on issues which occurred during their placement. Practice placements can be challenging for many students, as they attempt to feel their way into the profession, tackle specific educational tasks and processes, and, at the same time, understand the 'rules of the game' or norms of their new environment. Practice placements typically see students in unfamiliar settings, without known peers, and faced with new professional challenges. These experiences reinforce the sense of always being in transition throughout the nursing programme, rather than being integrated.
To summarise and connect the themes described here, there is a pattern where structural aspects of nursing degree programmes which inhibit integration, such as large cohorts or frequent shifts between academic and practice settings, are exacerbated by institutional attitudes and practices. Students' descriptions of common stress points, such as their first semester, first placements and first assessments, suggest limited efforts by institutions to address or mitigate these challenges. Indeed, some students describe implicit or occasionally explicit messages that coping with these challenges without support or fuss is viewed by their institution as part of the test of their 'fit' with a nursing career. The table below summarises some ways students often perceive institutions to be indifferent to challenges or to frame them as a necessary element of programmes and professional qualities. While a high degree of resilience is clearly required of qualified nurses, it may be institutional expectations are too high in the early stages of such an intense degree (Table 1).

The potential for using practice to integrate students into the programme
The diverse experiences of practice are widely recognised and discussed by nursing students. Even those with generally positive experiences are very aware there is a good chance of a really challenging practice placement at some point. Such difficult placements often involving inter-personal as well as professional or skill-based challenges. There is also an understanding among many students that their institutions only have limited power to ensure practice placements are of a good quality or that supervisors are motivated to support students. The lack of suitable placement sites for nurses is an ongoing issue for all HEI's in the study. However, a negative practice placement can have very important implications for the individual student's sense of integration and continuation in the programme. S1: You are very dependent on having a practice supervisor who is interested in having students... I had a one who did not want a student at all. Conversely, many students identify that a practice placement had a very positive effect, strengthening their determination to become a nurse. Practice placements can either consolidate or undermine students integration and course commitment.
Before the practice I felt unsure if I could do it [nursing], but after the practice I felt that I had more overview of what nursing was about, and that it would work out. So I actually got a boost after practice (Norway, female, year2, inst1). Everything you've learned previously you put into practice, so, you're seeing a worth of what you've learnt but you're also out there actually working with people and, like I say, what I enjoy doing and helping people and just constantly learning. It's massively challenging, you come home at the end of the day and your brain is zapped. (England,male,inst6) This student's sense that everything fell into place during his practice placement, despite it being challenging, was directly linked to the degree as worthwhile and a good fit for him. This manifested itself as a feeling of integration, not just as a nursing student but with the profession itself.
This finding also indicates the challenge associated with the organisation of placements, which are an essential component of the course. A few of the English students suggested that some of the issues they encountered on placement were a product of the (poor) organisation of their course. For example, one student felt that there was a lack of co-ordination and communication between the university and the placement providers, and subsequently students were required to take the initiative and liaise with placement providers about practical arrangements for the placement.
I thought it would be, to a certain extent, a bit more organised in terms of when you knew who your mentors would be, when you found out what hours you would be working and how far in advance you would find out. I thought a lot of that would be either the university would tell us, or placement would tell us, but that conversation would happen between university and placement, and that doesn't happen. (England,female,inst12) This sense of poor co-ordination is also found in the Norwegian data, and communication between the institution and the practice placements is not always perceived to be effective. Institutions with large numbers of students and placements struggle co-ordinating so many placements and negotiating and communicating individual arrangements. Some Norwegian students again raise their concern that the size of their cohorts results in them feeling alone, with no sense of where to seek help. This is illustrated by a third-year student: We are a bit alone as students. I wish I could go to school for guidance and help, and get a solution to the problems I feel that … Or, where I feel I have too little information and knowledge, I wish school was an arena for that. But it simply is not. It's more like 'you have to talk to the practice site about it', or 'that is something you have to learn at the practice site'. (Norway,female,year2,inst2) Even though this student is halfway through the programme, she is still uncertain of where to go to get information, support or guidance. This again illustrates the sense of being stuck in a continuous starting phase, lacking sufficient information or reassurance to proceed confidently This, combined with the constant flux, does not give many students enough time to integrate with their peers, their programme or institution.
A final issue in terms of practice placements links to this issue of social integration. Most practice placements are accompanied by meetings of groups of students on campus, to discuss and 'reflect' on their experiences in practice. However, the way these groups are organised varies enormously. Some institutions manage to keep students in relatively consistent and familiar study groups. In other cases, students meet to reflect and air challenges with an entirely new peer group.
We had meetings with the supervisor from the school and the other students who worked in the same nursing home, but not in the closed ward, no-one else said they thought it was scary, no one was afraid, and no one dared to say anything... So I felt so stupid, and I didn't want to share and say "oh, I found it gross and scary". Because we did not know each other from before, so we didn't have that openness. (Norway,female,year2,inst1) Where institutions organised student groups with little or no stability over time, students described it being hard to be candid and the groups offered more limited support. Rather, students tended to see these 'new' groups as performative arenas, to present themselves as successful in overcoming challenges, rather than an opportunity to discuss real challenges, concerns or any sense of doubt or failure.

Discussion
The stories of integration into nursing programmes told by students in Norway and England are strikingly similar. They describe challenges to becoming integrated with the programme and institution, through constant shifts in sites and groups, often with limited or no institutional support to effectively frame or buffer the experience of transition. These feelings of ongoing shifts and disruption, and for many of being left to sink or swim, persist not only through their first year but sometimes well into the second and even third years.
In contrast to a 'traditional' or typical undergraduate programme, where students are joining a cohort of peers, in a small number of physical places, nursing degrees span a range of sites and spheres. Students' descriptions depict an integration journey where they feel they are continually starting from scratch, learning about new topics, codes of expected behaviour, meeting novel peer groups and new sites, and there is little familiarity and stability, throughout the first year, and throughout the degree. Students' descriptions of their courses is that they are not experienced as an integrated process, or coherent learning journey, but as episodic: a series of discrete and disorganised chapters, which vary enormously in many ways. Even for confident students, these experiences have the potential to undermine, or build up, confidence and motivation. Nursing students largely navigate this journey individually, and they have a weak sense of a collective experience to reflect upon. The table below summarises how integration differs between traditional undergraduate programmes and nursing programmes ( Table 2).
The table highlights key contrasts in the nature of the integration process as traditionally depicted and described in HE theory and in relation to undergraduate degree experiences. Successful integration is framed in the literature, and addressed by institutions as a largely one-off process, typically taking place during the first semester or year, where a student integrates into a fairly bounded group and geographical site (e.g. course peers in a limited number of spaces and sites where the degree is taught). In contrast, the structure of a nursing degree, and the experiences described by student nurses suggest a much more complex, dynamic and fragmented. Nursing students go through multiple, iterations of integration into different groups of peers, professional colleagues, and sites across HE and placements. The integration process is disrupted and extended into subsequent years of study.
The interviews suggest that students grapple with the issue of integration; the interviews provide a powerful sense of students operating in, and attempting to get to grips with, multiple novel, complex and distinct spheres, but often remaining on the periphery and uncertain of their 'fit' with nursing. The interviews underline a clear set of common factors students perceive as helping or hindering integration. These tend to combine a structural or systemic feature of the programme with institutional practices which exacerbate it, or which legitimise inaction to mitigate it. In the case of the scale of programmes, large cohorts and anonymity, this is clearly a challenge for students developing a sense of a secure 'base' of academic peers, social support and a sense of belonging. However, institutional practices often seem to intentionally encourage and promote frequent and ongoing 'mixing up' of study and support groups. Practice placements also present an additional Multiple sites and shifting groups and significant challenge to integration. These sites are perceived as the ultimate test of a student's viability and progression as a trainee nurse, but there is, inevitably enormous variety in how each placement is run and supervised. Again, this hard-to-change feature of nursing programmes seems to be exacerbated by weak communication between HEinstitutions and practice placements, and a patchy set of practices for addressing those who have a bad placement experience which severely undermines confidence, progression or motivation. Finally, the intensity of the programme leads to a packed schedule, where students feel they have little time to consolidate or reflect on their learning or experiences, as they are immediately plunged into a new challenge and set of experiences. This lack of 'breathing room' is very significant if we consider theories of integration, which stress the centrality of reflection, where students 'close the learning loop' and develop a greater sense of academic or social integration. Again, a great deal of the programme structure and intensity may be inevitable, but there are cultural and institutional messages about needing to 'sink or swim' and that 'nurses don't complain' which seem to add to these pressures rather than mitigating them.

Conclusion: what are the implications for theory and institutional practices?
Integration into the programme and with their peers appear to be more complicated in nursing programmes than in standard academic degrees. Programmes take place across multiple sites and with multiple peers, teaching staff and professional colleagues, resulting in an ongoing process of integration. Students' experiences suggest an ongoing liminal period of disruption and disintegration, which they describe as impacting their confidence that they can and will complete their degree, and become a nurse. The complexity of integration for nursing students may pose an ongoing risk in terms of persistence; initially well-integrated students may subsequently be at risk 'disintegration', and of dropping out. These findings point to the need for an adjustment of Tinto's model, for it to be relevant for nursing students -and other professional education degrees (Thomas & Hovdhaugen, 2022). Hence, institutions should be aware that the integration process of these students isn't usually completed during the first year. The more cyclical, repeated notion of socialisation described by Weidman et al. (2001) captures the experience described by nursing students, and it may be helpful for institutions to recognise each stage of the degree as involving significant novelty or challenges to integration, even into the second and third years. Tinto's model as it is usually depicted, as a singular and linear process, would tend to under-emphasise the complexity and multi-dimensional nature of integration of professional education students.
We suggest it is important for institutions to recognise that nursing students experience extended periods of transition and an extended liminal state, where they are weakly integrated. Nursing degrees, as organised in Norway and England, may therefore expose students to an extended period of risk and vulnerability to early withdrawal. While some of the complexity and challenges described are inevitable parts of the professional degree structure, to accommodate a wide range of academic and practice-based study periods, we find evidence of organisational and cultural aspects of nursing degrees that seem likely to exacerbate integration challenges. There is scope to address areas where students' integration processes are frequently disrupted, and they are exposed to repeated 'transition shocks' delaying their integration into their study groups and degree programme. Programmes and institutions may need to take integration 'support work' more seriously. Future research could examine how institutions may better support nursing students' academic and social integration at each stage of their degree programme.

Declarations
Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
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