A nurse degree apprenticeship scheme in north-west England is demonstrating that apprenticeship is an effective strategy for nurse education and recruitment
The nurse degree apprenticeship scheme set up by the government to address employment shortages in the NHS is the subject of a parliamentary inquiry due to slow uptake nationally. University Hospitals of Morecambe Bay Foundation Trust is one of the first to implement the scheme and is reporting high satisfaction among apprentice nurses, staff and patients. The trust is confident it will prove an effective way of growing its own committed local workforce responsive to patient and geographical need.
Citation: Smith S et al (2018) Implementing the nurse degree apprenticeship scheme. Nursing Times [online]; 114: 10, 20-22.
Authors: Sue Smith is executive chief nurse/deputy chief executive; Joann Morse is director of nursing; both at University Hospitals of Morecambe Bay Foundation Trust; Lauren Mawson is principal lecturer in professional practice, University of Cumbria.
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Nursing degree courses have seen applications plummet by a third in the last two years and by 40% in the case of students over the age of 25 (Stephenson, 2018). The nurse degree apprenticeship scheme was launched by the government in 2016 as a means of addressing the recruitment crisis but has experienced a slow uptake among NHS trusts nationally and is the subject of a parliamentary inquiry. However, University Hospitals of Morecambe Bay Foundation Trust (UHMB) has pioneered the apprenticeship scheme in partnership with the University of Cumbria and, despite some ongoing funding issues, is demonstrating that apprenticeships are an effective way forward for nurse education and recruitment.
Through close collaboration between the university and the trust we have developed a flexible, bespoke apprenticeship scheme appropriate to our local needs and population. Early feedback shows a high level of satisfaction among the apprentices, staff on the wards and patients. We believe retention rates will be high and see this as an effective means of addressing a local nursing recruitment crisis, and producing a motivated, dedicated local workforce and place-based system of care.
The trust serves an ageing population of 350,000 people over a geographical spread of 1,000 square miles; it employs 2,000 hospital-based nurses and 800 community nurses across two acute hospitals (45 miles apart with a travel time of 1.5 hours), one elective site with an urgent care centre and four community inpatient facilities.
Nurse recruitment is a challenge due to high costs of living, accommodation and transport; while we are making slow progress with hospital recruitment many other healthcare organisations, including care homes and community services, have seen numbers of staff fall, with some care homes closing. This has an inevitable effect on the rest of the local healthcare system. One of our domiciliary care providers lost half of its staff when Aldi opened a store locally offering better pay, and we also compete with a vibrant seasonal tourist trade. Forty per cent of the hospital and community registered nursing and midwifery workforce at UHMB are over 50 years of age, so the need to address long-term workforce needs across the whole healthcare economy has been a key driver for implementation of an apprenticeship scheme.
Since 2014 the trust has run a two-year healthcare assistant (HCA) apprenticeship programme. Staff completing this were guaranteed an interview on the traditional registered nurse degree programme and half have gone on to take the degree course; a significant number of those who did not cited affordability as the main reason. Many had families and, although they would make excellent nurses, it was not an option for them financially. The development of an apprenticeship degree course has enabled these – and other candidates for whom a traditional nursing degree course is unaffordable – to pursue their ambitions and achieve their potential.
The executive nurse and her team at UHMB worked closely with the Department of Nursing at the University of Cumbria, supported by the regional branch of the Royal College of Nursing, to devise an apprenticeship that was robust and appropriate for local needs. We believe this partnership working is key to the success of the programme so far.
Recruitment and funding
Our first cohort commenced in February 2018, after receiving approval from the Nursing and Midwifery Council (NMC). Having agreed that we would recruit from our existing workforce, we received 93 applications; 43 applicants were shortlisted for interview and 27 were offered apprenticeships. Four of the 27 had been through our cadet course, nine through our HCA apprenticeship and two came from clerical roles within the trust. People wishing to access the nurse apprenticeship are required to work for the trust for a minimum of six months before applying to ensure they really understand how to care for patients. We believe this will deliver a very low attrition rate.
Apprentices are paid a proportion of a band 5 salary in years one to four, working up to full pay on qualification. Box 1 outlines this and other details of the scheme.
Box 1. The Cumbria model
- Four-year degree apprenticeship
- Recruitment from existing workforce
- Four days a week on placement – two days supernumerary
- One day a week in university
- 70-week hub-and-spoke placement model
- Salary: starts at 60% of the bottom of Agenda for Change band 5 in year 1, incrementally increasing to 75% in year 4
From April 2017, the trust paid into the new apprenticeship levy, which requires all UK employers with annual pay bills of over £3m to invest in apprenticeships. We are now drawing down funds to pay for the training of the 27 recruits.
While the levy covers academic costs, 100% of apprentices’ salaries are paid by the employer. This results in a significant additional cost pressure for employers in a time of financial austerity and we believe it is likely to be a key barrier to the apprenticeship programme being adopted more widely.
Curriculum and management
The apprenticeship curriculum pathway has theoretical content identical to the traditional nursing degree programme, and applies national educational standards as laid out by the NMC (2010). However, its delivery pattern has been adapted so that nurse apprentices experience the same education via a different route.
Entry criteria are the same as for full-time degree courses in terms of NMC requirements regarding literacy and numeracy, although we did apply some flexibility in relation to experiential learning and potential to succeed academically. For example, one applicant worked in a senior clerical position and produced reports that were equated with an A-level standard of writing.
In Cumbria we chose to orientate the programme around three 70-week hub placements – in surgical, acute care and medicine – to allow for flexibility in the rota and teams, as well as offering apprentices the opportunity to forge strong relationships with their teams and benefit from rich experiential learning.
While allocated to a hub placement, nurse apprentices spend four days a week working, two of which are in a supernumerary capacity; their remaining day is spent in university. A hub-and-spoke model allows apprentices to gain ‘spoke’ practice experiences in community and specialist settings. Hours are carefully monitored and documented via an electronic recording timesheet to ensure NMC requirements around regulations and hours are met.
Apprentices study the same modules and receive the same taught hours as full-time university students. The assessment of both theory and practice is identical, with the same three NMC progression points. Apprentices are monitored in terms of fitness to practise, and this is underpinned by an ongoing dialogue between the university and the trust.
The university has a designated pathway cohort lead whose role is to manage the apprenticeship pathway; she liaises with the trust’s senior nursing team. In the trust, apprentices are supported by mentors and practice education facilitators for clinical support, and a dedicated vocational services manager provides organisational and pastoral support.
The Education and Skills Funding Agency requires the employer, university and apprentice to have a tripartite meeting every 12 weeks. At Cumbria these meetings take place every 10 weeks, allowing us to audit how funding is being spent and what each individual apprentice has received. This helps to us to track how apprentices are developing and allows for action planning to make sure NMC standards and hours are being met.
Experience so far
The new nursing degree apprenticeships are very different to the apprenticeship model of the past in relation to both registered nurse and state-enrolled nurse qualifications. These ‘apprentices’ were paid by the employer and put on the duty rota as part of the team, rather than being supernumerary, and were often taught by an inadequate number of fully qualified nurses. The degree apprenticeship recognises the need for supernumerary time but also the importance of practice-based learning through supervised practice. Clear boundaries are set in line with NMC guidelines for rotas, and apprentices are supported by trained and designated qualified mentors to exacting standards.
Our apprentices are a mature group of individuals who are absolutely clear that this is what they want to do – nursing is their career aspiration and they are going into it with their eyes wide open. Their energy and desire to learn is palpable and their ability to reflect is inspirational; trust staff go out of their way to find learning situations for them all to ensure they have the best opportunity to learn and develop holistic nursing skills.
While we can demonstrate that apprentices are supernumerary for at least 15 hours every week, everything they do is a learning opportunity. They contribute to care while being supported through the Collaborative Learning in Practice model of learning. The degree apprenticeship takes four years to complete and gives access to a degree programme to a wider group of local applicants than the previous options. Traditional entry via UCAS does not allow for local applicants to be given any priority for places.
The extended placements and hub-and-spoke model allow apprentices to become embedded in a team, explore multifaceted types of care and understand how they are connected, building important relationships as they learn. Apprentices become part of a team and employment is more manageable in terms of annual leave and work-life balance. Flexibility in the programme enables them to follow a patient throughout their journey across primary and secondary care, giving them an overview of the patient experience, while developing strong relationships with partner agencies. Box 2 details the experience of being an apprentice.
Box 2. The apprentice experience
Helen Fawcett (pictured on the left) and Cherish Otoo, who are on the registered nurse degree apprenticeship programme in Cumbria, are single mothers who would have been unable to afford nurse training without the apprenticeship. Both were previous employees of University Hospitals of Morecambe Bay Foundation Trust: Helen worked as a healthcare assistant in accident and emergency (A&E), and Cherish in administration.
Cherish is based on the trauma and orthopaedics ward: “I really love it, it’s a fantastic ward, you really do learn so much while you are there. The mentors are so pro-active with teaching new nurses and are passionate about the apprenticeship, and 70-week placements mean that you become well-known within a team and everybody supports your learning. I feel I can be very open about where I need to improve.
“The wages are great for me; I did take a pay cut, but I can still run my house and look after my two children, which is all I wanted. It is a lot of hard work to get onto the scheme and to get the entry requirements but the rewards are fantastic – to be able to train and be paid. There is no student debt hanging over you.
“I think sometimes people’s perceptions are that, academically, we don’t work the same as the traditional student, but I believe once you explain to people that, academically, our work is exactly the same – we have the same essays and the same exams governed by the Nursing and Midwifery Council – then we are much more respected. We are the same nurse at the end of this, it’s just a different pathway.”
Helen loved her job as a healthcare assistant and, having been accepted on the traditional nurse degree course at the University of Cumbria, was extremely disappointed to realise that she could not afford to pursue it.
“I would have had to work all the hours god sends because the loan wasn’t enough. If I had a choice now though, I would still do it the apprenticeship way. It suits my learning needs as the majority of the learning is on the job with patients and is hands-on.
“When I work in A&E (which I still do as a healthcare assistant at weekends) I see patients come in the front door and rarely see them again; as an apprentice, I see them come on to the ward. I have been in theatre and seen procedures done on a few of my patients. I’ve looked after them in recovery and followed them back to ward, and sometimes been in outpatients when they come for follow-up. It’s an amazing opportunity to see the full journey for the patient.
“As healthcare assistants we know what being a nurse is really all about so we don’t have the false expectation that some of the traditional-route students might have. We know what we are letting ourselves in for and still want to do it!”
We are working to create placement opportunities across the healthcare sector, to develop apprenticeships and to build a community of healthcare relationships across the area. One challenge is understanding how we can enable local providers who do not currently pay into the apprenticeship levy to access the programme. We are working with Health Education England to explore how we might widen this opportunity to secure a flexible workforce that is capable of meeting the diverse needs of our population wherever they need care.
Another challenge is affordability: we need to look at how the financial burden can be reduced for employers by reviewing the potential service contribution or a funding stream to offset the costs associated with backfill for days when apprentices make no contribution to service.
Our ambition in Cumbria is to run two 100-strong registered nurse degree apprenticeship intakes each year, which will ensure our future workforce needs across the whole healthcare economy are met and sustainable. There has been a significant amount of national interest in the programme and we are happy to share our learning widely.
- The scrapping of bursaries for student nurses led to a 30% per cent drop in the uptake of university nursing degree places
- A nurse degree apprenticeship scheme was set up by the government in 2016 to help address the nurse recruitment crisis
- Poor uptake of the scheme has caused concern and led to a parliamentary inquiry
- A nurse degree apprenticeship scheme in Cumbria is reporting good uptake, as well as apprentice and staff satisfaction
- Close collaboration between University Hospitals of Morecambe Bay Foundation Trust and the University of Cumbria is seen as key to success
Nursing and Midwifery Council (2010) Standards for Competence for Registered Nurses.
Stephenson J (2018) Nursing course applications have crashed by third in two years. Nursing Times; 12 July.