Nursing student attrition remains stubbornly high – but support is out there
Nurse workforce shortages make the student drop-out rate a more pressing concern than ever
Nursing Standard survey suggests drop-out rates from UK nursing degrees remain stubbornly high – but nurse leaders and academics are devising strategies to help students who are struggling
With the profession struggling to cope with workforce shortages, the issue of nursing student attrition has never been more pressing.
But new figures collated by Nursing Standard suggest, despite recent government attempts to bring down nursing student drop-out rates, it is proving a stubborn problem to shift.
Our investigation, in collaboration with health research charity the Health Foundation, reveals one in four nursing students ends up dropping out of their course.
In total, 55 of 74 UK universities offering nursing degrees provided Nursing Standard with start and completion data for students on three-year pre-registration programmes for 2014-17. Out of 16,544 students starting courses in 2014, 4,027 quit their studies early, revealing an average nursing student attrition rate of 24%.
A long-standing issue
Nursing Standard has been monitoring the phenomenon since 2006 when our survey found the drop-out rate was 24.8%. In 2010, the rate was 28% and last year, 25.1% – so it's clear nursing student attrition has remained static for more than a decade, if not even longer.
Lord Willis, who led the Shape of Caring review into nurse education and training in 2015, described attrition as the ‘Achilles heel of the nursing world’. His review cited an average drop-out rate for nursing students in England as more than 20%.
In the same year as the Willis review, the Department of Health told Health Education England (HEE) it wanted to see a halving of the attrition rate. The Reducing Pre-Registration attrition and Improving Retention (RePAIR) project was set up to achieve this.
However, the baseline figure against which the effectiveness of the project can be assessed has never been published.
‘Student attrition has been for many years identified as a major problem for the UK, given nursing shortages are so prominent and increasing’
Professor James Buchan, nurse workforce expert, Queen Margaret University
The HEE final report on the project is due to be published shortly. The organisation would not be drawn on the report's findings or recommendations but a spokesperson said: ‘HEE has not only examined attrition rates but through extensive engagement, we have been gaining a detailed understanding of reasons why students choose to stay or leave and we are investigating the impacts of interventions that may help improve attrition.’
Nursing workforce expert James Buchan, professor in the health and sciences faculty at Edinburgh’s Queen Margaret University says: ‘Student nurse attrition has been for many years identified as a major problem for the UK, both in terms of the negative impact on individuals who leave programmes early, and also for the system at large, given nursing shortages are so prominent and increasing.’
Nationwide approach is needed
Professor Buchan argues the case for an agreed UK-wide approach to attrition, based on an agreed definition of it.
‘For several years, many have been arguing for the need for a standard definition and measure of attrition – and open access to this data – in order to support a targeted and co-ordinated response at university and national level in the UK.’
Some critics argue that examining universities’ completion rates on the basis of whether students have completed on time – the method adopted by Nursing Standard – is a crude measure of attrition. The reasoning goes that students who do not complete on time may still go on to continue their studies at a later date. Those returning students would not be captured in this data. However, others recognise that without an agreed measure of attrition in use, such as Professor Buchan advocates, this method is valid.
Council of Deans of Health (CoDoH) lead for education and impact Nigel Harrison says: ‘Sometimes people do take time out of their programmes and this has a major impact on the figures, but many of them do come back and the data doesn’t acknowledge this.’
'Let's talk about retention'
Professor Harrison, executive dean in the health and wellbeing faculty at University of Central Lancashire, says the figures don’t reflect the success stories of those students who return after stepping away from their programmes.
‘My preference is to call it “retention”, as attrition has negative connotations. With retention, you have a positive message that we are all in this together to improve the student experience and retain people.’
The professor acknowledges students do leave courses for diverse reasons, citing mental and physical ill health, academic difficulties and caring responsibilities as examples.
‘Rightly or wrongly women tend to have a lot of caring responsibilities. It is about how we support female students with those responsibilities’
Nigel Harrison, education lead, Council of Deans of Health
‘We do recognise that non-completion is very complex and, in terms of causes, it is about looking at individual student circumstances.’
The role of gender
He believes the gender disparity in nursing affects the figures.
‘We have a lot of female applicants, so there is a gender inequality in nursing. [These women], rightly or wrongly, tend to have a lot of caring responsibilities.
‘It is about how we acknowledge that as a challenge and what we can do to support those female nursing students with those responsibilities.
‘In my own university, we have achieved the Athena Swan bronze award, a gender equality charter, because we have taken responsibility, tried to be proactive and looked strategically at the issue of gender inequality as a faculty.
‘We need to promote and have positive role models and the presence of men in nursing.’
‘Negative experiences on placement drove me away’
Until recently, Daniel Garrod was a first-year children’s nursing student at the University of Bangor in north Wales.
He left his studies after growing disillusioned with his prospects as a male children's nurse. Mr Garrod, who was a mature student, did not agree with hospital policies that prohibited nurses who are men being providing care to girls while unaccompanied.
‘I loved the nursing but there were too many barriers being a male nurse and as a man I felt I was being singled out at times.’
Mr Garrod said he was reprimanded during a placement for talking to an ‘upset’ teenage patient while her mother had gone to get clothes.
‘Afterwards a ward sister came over and said as a male nurse I was not allowed to do that. I realised I could only be 50% of a nurse and that broke my heart.’
Professor Harrison believes there needs to be an integrated approach to nursing student retention.
‘If 50% of a nursing degree programme is theory and 50% is practice, the responsibility for retention is in the university, but also with our partner NHS and placement provider organisations.’
The CoDoH has been involved in developing a project on student leadership for nursing, midwifery and allied health professional students with the help of the Burdett Trust for Nursing. This project is now at the end of its second year.
Professor Harrison explains: ‘A key message has been that student peer mentors are really effective in listening to each other and helping [struggling students] not feel so alone.’
nursing students graduated from three-year degrees in 2017, compared to a 2014 starting figure of 16,544
Brighton University nursing student Gino D’Andrea has set up an online motivational support tool for his peers, having witnessed students leaving healthcare programmes. The website www.keepgoingstudentnurse.com generates inspirational quotations provided by nursing students and nurses with messages such as this one from a nurse director: ‘Keep going. You are making a difference every day. You are the future of this amazing profession and can take nursing beyond what I can possibly imagine.’
RCN head of professional learning and development Anne Corrin agrees reasons for attrition are multi-factorial but also says placement experiences are key and can create real lows or highs for students.
‘This is crucial – do they feel part of the team and do they have a nice mentor?
‘Good mentors can be key. A role model can inspire you if you are struggling on a course, as they keep people going, while a less interested mentor might cause a student to find it difficult to cope with that relationship.’
Dr Corrin says financial struggles often make it hard to stay the course and cites the example of nursing students having to make retrospective claims for travel expenses.
‘That is very difficult and there is an assumption there that people have the money to spend at the time.'
She says unless students take on bank work, they often experience financial difficulties, but that can affect their academic work.
‘One thing the RCN is suggesting is that maybe we have to have more maintenance funding for financially struggling students.’
Some universities that recorded some of the highest attrition rates in the Nursing Standard analysis said there were nuances not captured in the data.
‘They see other students on other courses doing 16 hours a week, compared to their 37-40. Being a “student” is far from being a nursing student’
Louise Nelson, head of nursing, University of Cumbria
The University of Cumbria (UoC) supplied data showing that of the 252 students who started pre-registration programmes in 2014, 151 completed in 2017, on the face of it an attrition rate of 40%.
But, a UoC spokesperson explains that 227 students began in September 2014 while the remaining 25 began programmes in March 2015 (and would not have been expected to complete until 2018). This brings the non-completion rate down to 33%.
A small number of other universities raised a similar issue.
The shock of the first year
UoC head of nursing Louise Nelson says most nursing student attrition takes place in the first year.
Dr Nelson believes, despite best efforts to warn new students, many do not realise quite how tough the course is.
is the average cost to train a pre-registration nursing student over a three-year programme
Source: Higher Education Funding Council for England
‘They see other students on other courses doing 16 hours a week, compared to their 37-40 hours. Being a “student” is far from being a nursing student.
‘The academic rigour and first placement can be a shock for them although we try hard to prepare them.
‘We try to explain the chances of getting a job are extremely high and you get two qualifications – a degree and a professional qualification.’
Dr Nelson, a mental health nurse by background, says she is fearful the cuts to the NHS bursary last year will continue to hamper mature students applying to nursing degree programmes.
‘The students getting through since the bursary finished tend to be younger – the mature group of students has had that life experience.’
Mental health first aid
She says another major problem the university is seeing is that of more students experiencing mental health difficulties.
‘This absolutely mimics society. We are seeing that at different levels, from mild and moderate anxiety and depression to quite severe mental health issues and we have been very concerned about this.’
was the highest nursing student attrition rate at a university and 5% was the lowest
To tackle this issue, the UoC is putting mental health first aid into the new nursing student curriculum and training staff so they know how to support students.
‘We are doing everything we can,’ she adds.
But perhaps not every lost student number is a disaster.
Why some attrition is a good thing
Professor Harrison warns it is important to recognise that sometimes it is not a bad thing that certain students leave programmes.
‘We are not necessarily looking for 100% retention’, he says. ‘There are times that, for public protection, it is the right decision if a student leaves, if there are issues with a student’s academic achievements or issues around fitness for practice.
‘It is appropriate sometimes to discontinue students if they are not appropriate for the profession.’
Ulster University head of school of nursing Sonja McIlfatrick agrees: 'On some occasions some students are not suited to the profession and so in this instance attrition can be positive.'
The hope in the nursing profession is that HEE's RePAIR report will detail action and solutions that will finally get to grips with nursing student attrition.
Identifying and supporting vulnerable students
The University of Northampton managed to bring down its nursing student attrition from 24% in the 2013-16 cohort to 10% in the 2014-17 cohort.
Subject lead for nursing Donna Bray secured funding from Health Education East Midlands to address student retention and three years ago brought in new staff.
Ms Bray says: ‘We bid to create a “super-supportive culture” for students and used the money to develop two nursing student support posts.’
These support leads are nurses by background and each works two days a week to provide focused support for students perceived to be vulnerable to leaving.
‘Those who experience bereavement, young carers and first-generation university-goers tend to be more vulnerable,’ explains Ms Bray.
‘Even if a student has to suspend their studies, the support leads keep in touch with them, because many students are lost once they suspend.
‘If you support them and the support workers meet them to ensure the issue they left studies for has been resolved or is being supported, this means they return to complete their programme.’
Each nursing student is given one practice development teacher who supports them through their placements by following them in practice for three years.
The nursing department bid for money from a central university pot to fund workshops on emotional resilience and developing students’ personal and emotional skills.
Ms Bray says the economic case for the support staff is clear. She gives the example of four first-years, 15 second-years and 10 final-year students withdrawing from studies, and says the equivalent monetary loss to the university would be around £200,000.