Nursing student attrition: why it happens and how to stop it
All sorts of pressures can force nursing students to quit their degrees, but help is out there
All sorts of pressures can force nursing students to quit their degree programmes, but help is out there
Why do some nursing students leave their course before completion? Whether it is because they are struggling to make ends meet, or to cope with the realities of nursing practice or the pressures of life, tackling attrition is becoming increasingly important as nursing shortages grow.
‘I don’t think it’s always financial,’ says Open University professor of nursing and vice-chair of the Council of Deans of Health Jan Draper. ‘It’s a complicated issue, and it can often be to do with personal reasons.
‘Bearing in mind the gender make-up of nursing, pregnancy, childbirth and caring responsibilities – including the stretched generation of people caring for those at both ends of life – can all be reasons why people leave.’
Your first placement can be a shock
For some nursing students, their first placement is eye-opening: ‘It’s at that point that they realise they’ve made a mistake,’ says Professor Draper. ‘There’s a whole issue about making sure they know what they’re coming into. Having some experience is vital.’
She argues that clinical placements can make or break a student’s overall experience, with their success depending on universities and employers working well together.
‘Nurse education isn’t just the responsibility of universities. Students need positive experiences in both contexts, with constructive learning environments and good practice support.’
Pay us the living wage on placement – we deserve it
For adult nursing student John Worth, one way to alleviate students’ financial hardship is to pay them the living wage while they are on placement. His petition calling for this to happen has attracted more than 350,000 signatures.
‘We’re all struggling a bit,’ says Mr Worth, who started his course at the University of the West of England in Bristol in February.
Like many of his contemporaries he is working part-time – as a community health carer – notching up anything from 20 to 40 hours a week. ‘That’s as well as doing 37-and-a-half hours on placement,’ says Mr Worth. ‘It’s a real challenge. It’s harder than I thought it would be.’
'I couldn't afford to do the course without working too'
As a mature student who spent the previous six years as a senior healthcare assistant, he has overheads, such as running a car, alongside family responsibilities including contributing to rent. ‘I have to work otherwise I wouldn’t be able to do the course,’ he says.
While nursing students on placement are supernumerary, they play a vital role in clinical settings, Mr Worth believes. ‘I feel I’m working,’ he says. ‘I’m observing and monitoring patients, keeping the rest of the nursing team up-to-date with how patients are progressing. I understand we have to make up our clinical hours to be able to join the register, but I feel we are more like free labour for the NHS.’
'My friends already talk about giving up'
Despite the difficulties, Mr Worth is keen to continue. ‘I’m really enjoying my placement. I love the practical side of nursing and I want to make a career out of it,’ he says. ‘I’m determined to finish, but everyone in my group of friends has already talked about giving up, some mentioning it more than others.’
Working hard, having little rest and worrying about making ends meet is a strain on students’ mental health, he says. ‘We’re working six or seven-day weeks, with no time to wind down or socialise,’ says Mr Worth. ‘If we received the living wage when we’re on our placements, it would mean we weren’t wearing ourselves out, putting ourselves and our patients at risk. I would be able to focus more.’
Strong partnerships between universities and their local employers are crucial. ‘Good practice includes making students feel welcome and a part of the organisation,’ says Professor Draper. ‘They should value the fact they have students, and that they are integrally involved in training the next generation of nurses.’
Good employers take having students seriously, she says. ‘They are ready for them, rather than surprised to find them there. They welcome their questions and feel they bring a breath of fresh air, encouraging staff to think about doing things differently, with a willingness to being open to change. It’s much more than just ticking off competencies.’
‘Supporting students in practice is a skilled endeavour. People need to be willing to take it on in the first place and then be well trained’
Jan Draper, vice-chair of the Council of Deans of Health
Mentors, who will become practice assessors under the new Nursing and Midwifery Council (NMC) standards for education and training, should be supported, enthusiastic and eager to support learners, she says.
‘Supporting students in practice is a skilled endeavour. People need to be willing to take it on in the first place and then be well trained and updated regularly.’
When problems pile in
Adult nursing student Grant Byrne began his studies at age 18. ‘I came straight from school,’ he says. ‘I was excited.’
Studying at the University of Glasgow, he had a bursary of more than £500 a month. Initially that felt like a lot of money, he says. ‘But when you need to live off it, you realise it’s not so much.’
Juggling studying, placements and a part-time job in a call centre, combined with some family problems, led to him having to re-sit his second year, with no financial support. At the end of his third year, he failed his final exam. Family illness, working too many hours and a difficult placement all contributed to this, he believes.
‘Things were slowly unravelling,’ says Mr Byrne. ‘Failing made me feel really stupid. But I was working almost full-time a lot of weeks, alongside placements, plus studying and travelling an hour or two each day. Looking back, I can see what happened but then I just wanted to get through it. If I’d reached out, perhaps I would have had more support.’
'I love nursing – I never had any doubts about that. It was just trying to fit everything else in'
Grant Byrne, nursing student
After working for a couple of years, he applied successfully to Edinburgh’s Queen Margaret University and has just completed his second year, where he achieved 100% in a recent exam. ‘I’m back where I need to be,’ says Mr Byrne, whose ambition is to work in public health.
‘I’m so pleased because I love nursing. I never had any doubts about that. It was just trying to fit everything else in. But things feel totally different this time around. It makes me feel better about the past. And come the end of it, I think I’ll be a better nurse for having gone through it all.’
Today he works a limited number of hours, making sure he gets enough sleep. ‘I’m a lot more careful, because I know where my limits lie,’ says Mr Byrne. ‘I think my big problem was that I didn’t speak to anyone. I didn’t want to tell anybody what was going on at home, as it didn’t feel like my story to tell. But it’s so important to ask for the help you need.’
Making the wrong choice
At the Robert Gordon University (RGU) school of nursing and midwifery in Aberdeen, statistics show that making the wrong choice is the most likely reason why students leave.
‘The reality of the course isn’t what they expected,’ says RGU’s academic strategic lead for student experience and enhancement, Neil Johnson. ‘It may be the placement didn’t align with their hopes, the demands of degree-level study or the topics covered. It can also be the challenges of being a full-time student.’
In Scotland, students continue to receive an annual non-means-tested bursary, which is currently £6,578 a year for three-year courses. In addition, there are allowances for lone parents, children, disabled students and those who care for family members, with clinical placement expenses for some extra travel and reasonable accommodation.
‘But in reality, the bursary only covers basic living costs, such as rent, and many students still have to find part-time work,’ says Mr Johnson. ‘You can only expect students to generate so much income, especially when they’re on placement for 37-and-a-half hours a week.’
‘To give up because of money would be heartbreaking’
Anna (not her real name) is a children’s nursing student at a leading London university.
‘My first year was fine, but we’ve ended up doing a lot more placements in the second year. I have several part-time jobs but they haven’t been able to provide me with as many shifts, so I’ve found myself in financial hardship. I applied to the hardship fund at university and was given some money, but I’ve since run into hardship again – and you can’t apply a second time in a year.
‘In London, I get the maximum bursary of £547 a month and my rent for a room is £500. My student loan has to stretch to everything I need for the course, including travel costs. On placement, these are much higher as I have to travel at peak times, but there are no expenses if you’re travelling within the same zones as you would to attend university.
A friend donated my rent
‘A good friend has very kindly donated some money to pay my rent, otherwise I would have been forced to leave the course. I’m the last cohort of the bursary, so if I postponed for a year, I would have to come back on the student loan [without the bursary]. I was absolutely gutted at the thought I might have to give up. I’ve really found my feet now and am discovering things about nursing that I love.
‘I’m an active student and one of my roles at the university is about widening student participation, working with young people from disadvantaged backgrounds. To have got this far, and then to find finance is the reason that you might not make it, is heartbreaking.’
RGU enrols an average of 300 nursing students each year, with the aim of keeping attrition well below 20%. Historically, attrition rates have been higher in Scotland than the rest of the UK. The most recent figures date back to 2011, when NHS Education for Scotland said around 27% of preregistration diploma students left their course. ‘Inevitably some students will fall by the wayside, but if we’re losing them, we want to know why,’ says Mr Johnson.
He believes the starting point for reducing the numbers who leave is recruitment and selection. Among RGU’s initiatives is an access to nursing programme and a week-long summer school that includes an observational practice visit designed to introduce imminent school-leavers to nursing as a career choice.
Tips to help you make it to graduation
- Familiarise yourself with your university’s support systems, advises Robert Gordon University’s Neil Johnson. ‘Find out at an early stage where you can get help if you need it’
- Keep going and don’t give up at the first challenge, says Open University nursing professor Jan Draper. ‘Turn challenges into learning points and opportunities.’ Student Grant Byrne adds: ‘Not every aspect of nursing is for everyone. It’s okay to say, this is a great ward but it’s not where I want to work.’
- Ask questions and voice any difficulties. ‘There’s no such thing as a silly question,’ says Mr Johnson. ‘If you don’t ask, we assume you’re satisfied.’ Professor Draper agrees: ‘Don’t be frightened to ask for help, share how you feel or admit you don’t know something’
- Remember you’re not alone. ‘Build a community of like-minded people around you who are also negotiating the same kind of things,’ says Professor Draper
- Engage with the wider student experience and population. ‘Enjoy being a student in higher education. Immerse yourself in it,’ says Mr Johnson. ‘We should think about what we get from going to university,’ says Mr Byrne. ‘It’s an important part of most people’s lives. Yet some nursing students don’t even get to join a sport or society, which is such a big part of other students’ experience. It’s how you make friends outside the nursing bubble’
- Build your emotional resilience. ‘Learn how to feel comfortable about going into uncomfortable situations,’ says Professor Draper
- If you’re struggling, don’t be afraid to take time away, says Mr Byrne. ‘It’s okay to let other things come first for a little while, nursing isn’t going anywhere. Most universities will support you and you can then come back and be the student you want to be’
- ‘Try to remember your initial motivation, what brought you into nursing in the first place,’ advises Professor Draper
Sustained support for the individual
RGU also uses values-based interviewing. ‘We’re selecting students, rather than just recruiting them,’ says Mr Johnson. Successful applicants all have a personal tutor who follows them throughout their three-year course, meeting students at least once each semester and more often in their first year.
‘They monitor progress, intervening if students aren’t engaging, or they are struggling to pass assessments,’ Mr Johnson explains. ‘If a student is having difficulties or feels unsettled, they can chat to their personal tutor in the first instance to see what support is available.’
‘We try to do a lot to enhance support for students, giving them the best chance to stay on their course’
Neil Johnson, academic strategic lead for student experience and enhancement, Robert Gordon University
They also use a variety of tools to help identify students who might be having problems, including self-assessment, attendance, sickness absence and feedback from practice. For some students, dealing with emotionally difficult situations during placements can also be challenging.
‘When they go into practice, they are in the real world – it’s not simulated,’ says Mr Johnson. ‘We try to do a lot to enhance the support for students with a multi-faceted approach, giving them the best chance to stay on their course. I think those who are at risk of leaving early perhaps just need that extra bit of signposting to sources of support, helping them gain the confidence to carry on.’
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Lynne Pearce is a freelance health writer