Reports of high attrition rates among pre-registration nursing students are obviously not good. It wastes health service money and contributes to the ‘boom and bust’ cycle so familiar in NHS workforce planning.
But despite the problem’s importance, there is a surprising lack of accurate data on attrition rates for UK nursing students.
Suggested rates for England vary significantly. Figures from the Higher Education Statistics Agency reported the attrition rate as 16% for the 2003–2004 intake – a fall from 18% in 2002–2003.
The NHS Workforce Review Team, a national body that helps strategic health authorities with workforce planning, predicts that current cohorts will experience an attrition rate of 20%.
The union Unison, however, estimates that the current attrition rate may be as high as 25%.
‘One of the problems is that attrition is not effectively monitored,’ said Gail Adams, Unison’s head of nursing. ‘But our findings suggest rates are higher than 16%.’
Figures for Scotland are also higher. Data released by NHS Education for Scotland earlier this month show the attrition rate for the 2002–2003 cohort was an average of 26.4% across all nursing branches. In paediatrics that figure reached 31.3% (NT News, 5 February, p8). And while pre-registration training places commissioned in Scotland have increased by about a fifth in the last five years, the attrition rate has increased by the same – up from 22.1% in 1998–1999.
The rate may also be on the rise in Wales, according to recent research on nursing student attrition, presented in December by Swansea University lecturer Lynne Walsh.
While the figures are potentially worrying, a Commons public accounts committee report, published last week, suggests they are not dissimilar to rates on other university courses.
The average percentage of students in England failing to complete their higher education course has remained at a static 22% for the last six years.
Gill Devereaux, Unite/CPHVA professional officer, said that, although similar to the national norm, the impact of student attrition on nursing and the NHS was more significant because of its more direct effect on the workforce.
‘In nursing it’s a workforce issue because of the way workforce planning is done, so the impact is different. If resources are very tight and you’re investing money in training places from a financial perspective that’s worrying.’
To address the attrition rate, the profession first needs to find out why students are leaving.
A recent study, published in the Journal of Advanced Nursing, suggested that the verbal abuse experienced by some students in training could have negative physical and psychological consequences, which could lead to increased attrition.
Meanwhile, Ms Walsh’s research, a qualitative study of students who completed their first year of training, highlighted four key themes – financial issues, course structure and timetabling, lack of support and a lack of confidence about whether they were developing the skills needed to work on the wards.
One respondent to the study said: ‘I know we have got another two years to go but I do think we haven’t had enough practical experience.’
However, finance was cited as the main reason for attrition. ‘The bursary doesn’t even cover my childcare and no matter what financial assistance there is, you have to dig tooth and nail to get it,’ said one student.
Financial hardship was also highlighted in Unison’s response to the NMC consultation on pre-registration training, submitted earlier this month (NT News, 19 February, p3).
‘The current level of the bursary has left students graduating with high levels of debt and the average now stands at almost £15,000, which is £4,000 less than a qualified nurse’s salary,’ Unison said in its response.
Other unions agree students need better financial support to help them complete training.
The RCN and Unite/CPHVA have called for changes to the bursary system, which sees bursaries available to all diploma students but only means-tested bursaries available to those undertaking a degree in England.
RCN head of policy Howard Catton said: ‘There’s a financial disincentive for graduate nurses who are disadvantaged because they do not receive a non-means tested bursary. We absolutely want to see that financial disincentive removed.’
Unison, however, has proposed a much more radical solution. It wants to see a return to the employment of nursing students. The union admits that paying students a salary carries an upfront cost but argues that salary status would significantly cut the attrition rate and be of cost-benefit to the NHS and the tax payer in the long term.
The union’s own research suggests the attrition rate in seconded HCAs can be as low as 2%, and it says employing students would create a greater psychological bond and sense of obligation to the NHS.
‘Salary funding would deliver more effective value for money, transparency and accountability in the use of public resources as well as non-financial benefits in terms of the quality of service delivered to patients over the long term,’ the union said in its consultation response.
However, the idea has met with opposition from other unions. ‘The real danger about going back to paying people is that they then become treated as part of the workforce – they become incorporated into staffing rosters and they lose their supernumerary status very quickly,’ warned Mr Catton. ‘There’s a danger they become just another pair of hands available to do the job.’
But Ms Adams disagreed. ‘I’m acutely aware that the suggestion is very provocative and will not have support among some people. But as far as I’m concerned some of the standard arguments put forward no longer hold ground,’ she said.
‘Some colleagues feel it would undermine supernumerary status but [seconded] HCAs are doing exactly the same clinical placements and the same hours, and it hasn’t undermined their supernumerary status or their level of academia,’ she added.
It will never be possible to reduce the attrition rate to zero but the low rate among seconded HCAs and the wide variations in drop-out rates between universities suggest more could be done to retain pre-registration nursing students.
All agree that in the first instance better data is needed to fully understand the scale of the problem before the profession can tackle it effectively.
‘There are a lot of assumptions that are made about why people leave,’ Ms Devereaux said. ‘But we need to have more reliable data before we can really start to address this problem.’