War on attrition: government tackles drop-out rates on nursing courses

Health Education England has been told to reduce drop-out rates by 50%.

High numbers of students dropping out of nursing courses have been a concern to the profession for decades. But efforts to reverse the trend are now underway, with the government instructing Health Education England (HEE) to reduce ‘avoidable’ drop-out rates by 50%.

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The average drop-out rate for nursing students at universities in England is more than 20%, according to the Shape of Caring review into nursing education, published last year. It warned that on some courses the attrition rate was as high as 50%. 


reduction in avoidable attrition target from the Department of Health

The HEE group looking into the issue, Reducing Pre-registration Attrition and Improving Retention (RePAIR), is working with universities in England to identify effective ways to reduce attrition.

The RePAIR group, which is due to report next year, will be looking for examples of best practice, and how to spread successful approaches across the country.

Workforce and education leaders, and the RCN, have described the 50% target as ambitious and challenging.

Range of factors

Research into attrition suggests that a complex number of factors influence a student’s decision to leave or stick with a course.

An RCN survey of 4,500 students in 2008 found that 44% had considered leaving their course; financial concerns, poor-quality clinical placements, doubts about career choice, childcare and travel difficulties were among the reasons cited.

Researchers say the definition of what constitutes attrition has been variable, and data collection on this topic has been patchy or often non-existent.

Senior lecturer in children’s nursing at London South Bank University Stephen McKeever undertook research into why students leave courses. 

He says it was difficult to get a response from students who have left courses – he contacted 176 children’s nurses who had dropped out and only five agreed to be interviewed.


the estimated cost of training a nurse

‘The primary reasons for going were academic failure or personal circumstances, followed by wrong career choice,’ says Dr McKeever.

‘There were lots of other factors that influenced them, and many students had unrealistic expectations before they started. There isn’t any one thing that would cure it all. We need a more realistic picture of what children’s nurses do so that students have a much better understanding of what being a nurse is.’

Nursing courses will always need a level of attrition to ensure that unsuitable students do not enter the profession, he adds.

Dr McKeever says the personal tutor is crucial to supporting students through the course and encouraging them to stay, but adds that the level of training provided to them is variable. ‘The position is not given the priority it needs to provide pastoral care.’

Change in funding

Another factor that may fuel attrition is the removal of the bursary in England from August 2017, to be replaced with tuition fees and loans.

RCN deputy director of nursing Stephanie Aiken says one potential outcome is that nursing students are likely to have higher expectations from the courses and their placements if they are paying £9,000 a year to attend.

Unions estimate that future nursing students will graduate with up to £50,000 of debt, and it is unclear what kind of impact this will have on whether students wish to stick with the course.

‘Anecdotally, where students are paying for education, they are expressing dissatisfaction with placements,’ says Ms Aiken.

Another concern is the lack of investment in mentorship, she adds: ‘There is a reduction in numbers of mentors available while there is increasing demand on mentors, both with the nursing associate role and other demands.’

Attrition rates on some nursing courses are as high as 50% (Source: Shape of Caring review)

Attrition from undergraduate nursing courses was described as the ‘Achilles’ heel of the nursing world’ by Lord Willis, in his Shape of Caring review.

Lord Willis told Nursing Standard that he found the levels of attrition from courses and the nursing workforce ‘staggering’.

He believes that standardised attrition figures should be published by every institution annually, which record why a student has left so that problems can be addressed. Nursing students should have their fees paid by NHS employers in return for committing to work for the trust for a number of years, he says.

While Lord Willis adds that he is pleased with the HEE’s work in this area, he says more needs to be done so that those already in the workforce are not ‘savagely overworked’.

He adds: ‘It is not just about HEE setting targets or demanding action. It is really about universities and employers creating a role that these people want to stay in for the rest of their careers.’

Better support for students 

Attrition rates are falling on nursing courses at Birmingham City University thanks to a campaign to improve support for students before, during and after their studies.

Drop-out rates on nursing courses at the university are between 10% and 12%, depending on the branch of practice, says head of the nursing and midwifery school Carol Doyle.

She is working towards a target of getting attrition below 10%, and the university wants numbers of nursing drop-outs to reduce by 1% each year.

Work at the university has included setting up contact days for students before they start, and a buddy system between first- and third-year students. 

A room for students to practise any clinical skills they may be struggling with has been made available, and a project providing additional support for black and minority ethnic students has been running for two years, because attrition rates for students from these backgrounds are higher.

The university focuses on building a community spirit with its students, Ms Doyle says. 

‘We find Twitter useful because staff and students are often online in the evenings and at weekends, so if staff spot any messages that suggest problems, they can say, "If you are feeling down or not happy, come and talk to us". It is amazing how candid students will be on social media.’

Birmingham City University is one of the universities that is testing strategies for HEE’s RePAIR programme to tackle attrition.

‘It is always going to be challenging reducing numbers but we are working at it steadily,’ says Ms Doyle.

‘HEE set a target to reduce it by 50%. It is difficult but everyone is working towards it and the target is high on our agenda.’

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