Problems with staff retention

There are more than 46,000 registered nurse vacancies in the NHS, and registered nurse numbers in social care have fallen 36% over the past decade. The latest Universities and Colleges Admissions Service (UCAS) data suggest a 7% reduction in the number of nursing students starting courses this year.

RCN deputy director of nursing education, research and ethics Nichola Ashby says: ‘Nursing educators in practice and universities are clearly under enormous pressure, and many are now leaving the profession.

‘This is leaving some students struggling to access placements and adequate tuition time. There needs to be urgent action to address all of these issues, or the nursing workforce crisis will only continue to grow.’

The government and NHS leaders say they are focused on retaining nurses following the demands of the pandemic.

But is there enough focus on retaining future nurses who embark on nursing degrees?

The latest annual Nursing Standard investigation into undergraduate attrition found 12,901 of 19,185 nursing students who began three-year degrees in 2018 finished their studies on time, in 2021 – leaving 6,284 (33%) who did not.

Studying during the pandemic

Added to the usual pressures, this cohort had to contend with the COVID-19 pandemic.

The experience had a devastating effect on students, according to Kevin Crimmons, Birmingham City University’s head of adult nursing during this time. ‘Students might have three or four months worth of hours to claw back, and they just didn’t have the time,’ says Mr Crimmons, now head of adult nursing at Newman University, Birmingham.

‘Some had to do lectures and academic work at home. All they had was their phone, as they weren’t allowed in the library.’

He adds that nursing is one of the hardest courses at university, and educational institutions need to be clear about what it takes to pursue a career in nursing. ‘I take my hat off to nurses that get through the course because it’s like doing an honours degree in 18 months, [given the] many hours of placements. We have to be clear in recruitment about what they are getting into. The reality is: it is hard. There is no slacking off.’

The demographics of nursing students could also be playing a role in rising attrition rates, with some facing more financial and social pressures.

According to UCAS data, 41% of the 28,540 students accepted onto nursing degree courses in 2018 were aged 25 and above, and 91% were women.

Mature students are more likely to have financial commitments, such as a mortgage, as well as children and other responsibilities.

‘They might need to leave if a partner loses their job or a family member is ill,’ says Mr Crimmons. ‘Most of our students are ‘commuter students’ who live at home and are the first in their family to go to university. The government doesn’t give them enough to live on which puts them in an oppressive situation.’

Revamping clinical placements

One issue that has divided opinion on attrition is the potential remedy of reducing clinical practice hours.

UK nursing students must complete 2,300 hours of clinical practice placements before they can qualify as a nurse, as stipulated by the Nursing and Midwifery Council (NMC). In contrast, Australia only requires 1,000 hours, while the USA requires fewer than 900.

In a 2020 report, the Health Foundation mooted increasing the use of simulation-based clinical experience, or reducing the total clinical practice hours needed for students to join the NMC register. Last year, the regulator announced the decision that 600 of the 2,300 hours could be carried out in simulated wards, a measure brought in during the pandemic.

Mr Crimmons welcomes the change but thinks it is not enough. He says that, with increased pressures on staff in clinical placements, university simulation wards could offer valuable practices, insights and routines for good practice that are sometimes overlooked on stretched wards.

An NMC consultation is underway on its education standards, including a review on contact hours. But the regulator says there is ‘little appetite’ for reducing the number of practice hours students need to complete.

How Nursing Standard gathered the data

Nursing Standard asked UK universities to provide start and completion data for nursing students who began three-year degree programmes in 2018-19 and were due to graduate in 2020-21 (or 2022 in cohorts that started in early 2019).

The data were collected through Freedom of Information requests emailed to universities on 3 July 2022. Of the 82 universities offering nursing courses that were approached for data, 67 returned completion data.

In total, 49 out of 64 in England, five in Wales, 11 in Scotland and two in Northern Ireland sent data. Four universities were unable to as they had only begun offering courses in 2021, or had no undergraduate nursing places.

Findings were analysed by Nursing Standard staff. Nursing Standard has been collecting this information since 2006 and annually since 2017.

‘No substitute’ for ward learning

NMC executive director of professional practice Geraldine Walters adds that there will be a variety of reasons behind a student’s decision to step away from their nursing degree.

‘While there is little evidence to suggest what the optimum number of practice hours should be, there was limited support for changing the number of practice hours we require,’ Professor Walters says.

‘Many think that there is no substitute for learning time spent in practice with patients.’

Despite a 2019 recommendation from the Reducing Pre-Registration attrition and Improving Retention (RePAIR) project to establish a standard definition of attrition across healthcare programmes, there remains no such definition.

The Department of Health and Social Care (DHSC) says the data is ‘misleading’, as it does not account for those who have paused their studies.

‘This is common among mature students or those who switched courses, for example to a specialism in nursing,’ says a DHSC spokesperson.

However, as Nursing Standard has been collecting figures on the course completion rate within cohorts since 2006, this data is comparable over this period. What it reveals is that, for more than a decade, the attrition rate remained at 20-25%, but last year it rose to 33%.

I thought ‘I can’t do this anymore, it’s too hard’

Emma (not her real name), a nurse who completed her degree in Birmingham in 2021, considered quitting university due to the pressures of the course.

Picture credit: iStock

‘First year was hard,’ she says. ‘People dropped like flies. Every term you’d go into lectures and there would be loads fewer people than the one before.

‘I don’t think any of us realised the pressure we would be under. My sister, who did criminology, just partied all the time. You can’t do that with nursing – you have to be at your shift at seven in the morning.’

In second year, the course got harder as the workload increased; Emma struggled to get to work on time using multiple buses and trains to travel all over the West Midlands for early placements.

‘There was a time when I thought I can’t do this anymore – it’s too hard,’ she says. ‘With all the learning, the placements, and the dissertation it just feels too much to cram in. It would have been much easier to cope if the course [took] four years.’

In her second year, Emma was assaulted by a patient who backed her against a wall and spat at her.

It was absolutely vile,’ she says. ‘I remember thinking, “Why I am doing this? I am not even getting paid.. Is this what I have to look forward to?”.’

Despite these challenges, Emma qualified as a nurse last year and is now working in the community.

‘I was lucky to have such a strong support system,’ she says. ‘There were a fair few moments I thought about leaving – whether financial, due to COVID-19, the experience on placements, or due to my university work. My parents and sister gave me the strength to keep going.

‘Other students might not be so lucky and no wonder they decide to walk away.’

‘There were a fair few moments I thought about leaving – whether financial, due to COVID-19, the experience on placements, or due to my university work’

More transparency is needed

Data from the Higher Education Statistics Agency (HESA) gives broadly the same picture – although its data is not broken down into cohorts and includes re-joiners who graduate. Despite higher intakes of students in recent years, graduate numbers remain below 25,000 a year.

HESA figures show that 23,875 qualified in 2020-21 – the lowest number since 2014-15.

Nursing workforce expert James Buchan, University of Edinburgh visiting professor and a Health Foundation fellow, says a standard method of presenting and recording nursing student data must be agreed to track attrition effectively.

‘There’s some reluctance from universities to put this data in the public domain, as some will have higher numbers than others. But if we want to deal with the problem, we need to understand the scale of it, and the patterns. Then we can fix it,’ he says.

A DHSC spokesperson told Nursing Standard there is ‘a strong pipeline of nurses’ – citing a 28% rise in the number of acceptances into nursing and midwifery undergraduate courses in 2021, compared with 2019.

In an update on its nursing workforce programme in March, DHSC noted ‘significant increases’ of 72,000 nurses coming from education and training in 2019-2024. It did not expand on how this estimate was calculated or supported by data.

Professor Buchan says there has been a clear surge in attrition in recent years, but it is unclear whether this is due to pandemic pressure, financial reasons or something else.

Students face a challenging time ahead as the cost of living crisis continues

Picture credit: iStock

‘Clearly, whatever is going on, there’s a bigger challenge,’ he says, highlighting the 7% reduction in nursing student intake and number of students completing courses as indicators that the potential pipeline is going in the wrong direction.

‘The next few months will certainly be challenging for students who are trying to get by as the cost of living increases.’

Why do nursing students leave their course before completion? rcni.com/student-attrition-2020

Further information

The Health Foundation (2020) Building the NHS nursing workforce in England: Workforce pressure points tinyurl.com/THF-workforce

NHS Health Education England: RePAIR project tinyurl.com/HEE-attrition