Nursing studies

Low-paid ‘on-the-job’ nursing student training will take the profession backwards

Paid clinical placements are no cure-all for student debt and staff shortages

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The past few months have raised some difficult issues for nursing students, not least the decision taken by some to choose an extended – and paid – clinical placement, as part of the country’s response to the COVID-19 pandemic.

Paid placements were offered to nursing students to bolster the COVID-19 front line 

In practice, this has led to a good deal of confusion, particularly in terms of employment rights, contracts and students’ status in the workplace. It has also reignited the long-standing, and sometimes heated, conversation about whether or not nursing students should receive a salary to train.

On the face of it, having a wage, especially when you’re struggling to make ends meet or you are worried about getting into debt, is an attractive proposition. Some students have already given their backing to the idea.

But before we seize on this as the solution to student hardship and shortages of qualified staff, it’s vital we reflect on what happened in the past, and how this model may, or may not, be working for other professional groups.

We need to fully appreciate its significant disadvantages too, particularly for a workforce where safety is critical.

A return to on-the-job learning would remove the safety net for nursing students

Over recent weeks, I’ve seen some people advocating a return to a traditional ‘learn on the job’ style of apprenticeship. This would involve being paid a very low salary – the current rate is £4.15 per hour for the first year of an apprenticeship, before moving to the minimum wage for their age.

The argument is that nursing students on placements are working, so therefore should be paid. But they are not registered nurses – that is what they are training to be.

It seems that the real issue is the variable quality of some of these clinical placements. Undoubtedly, persistent nursing shortages are having an adverse effect on some students’ experiences in the workplace, with some saying they are treated as healthcare support workers rather than nursing students.

But would being employed actually resolve these issues?

As an employee, a nursing student would lose the safety net that universities provide. There have been cases where students have been effective whistleblowers, raising concerns when patient safety has been jeopardised – would this contine to be the case?

Being an employee may detract from the learning experience

Crucially, they have had the full support of their university. But as an employee, would they have felt as comfortable speaking out? Or would they have felt beholden to their employer, with anxieties about passing their course, the kind of job they might get at the end of their training, and the quality of their education taking precedence?

Early burnout is another risk factor, with employed trainees having little opportunity for structured reflection or support. Rather than complain about poor working experiences, disenchanted staff tend to vote with their feet.

The current system also enables nursing students to access a wide variety of different placements – including in the community and increasingly GP surgeries – so they can fully explore a diverse range of options before making decisions on their future career. It would be difficult for any employer to replicate these opportunities.

Historically, moving nurse training into universities has been viewed by some as simply about improving the status of the profession. But there were other very good reasons too, including countering the extreme variability of training and lack of prospects for some students.

Resistance to nursing degrees is part of ‘an insidious narrative’

Black, Asian and minority ethnic (BAME) women in particular were disadvantaged by the old system, with many being pushed into becoming state enrolled nurses rather than registered nurses.

Unfortunately, there is still resistance even now to nursing being a graduate profession.

There is an insidious narrative that women’s work – and nursing is seen as that, regardless of the fact that it is also done by men – doesn’t need an education programme. As long as you are kind and compassionate, that’s good enough. If nursing were to return to on-the-job training, these old stereotypes will be reinforced.

‘Low pay for on-the-job training is reflective of recent government policy, which appears to be about having the most hands for the least money. It may well provide a low-cost solution to a staffing crisis, but it is unlikely to provide better care for patients’

Other commentators are arguing in favour of a more modern nursing apprenticeship, but these have been shown not to be financially viable.

While it is appropriate for apprentices in different professions to spend just one day a week at university, nursing is very different; while nursing students are gaining the necessary theoretical underpinning at university, employers are paying their salary and having to find the money to backfill their post when they are not at work. Some are paying course fees too.

On-the-job training appears to be about having the most hands for the least money

So where might the answers lie? It’s clear the funding model for nurse education is not working in its current form and needs urgent action.

When the bursary was in place, the average age of entry to nurse education was 27. Mature students made up the bulk of the nursing student population, and over the past couple of decades we have relied on mature students, largely women, coming into the profession. 

The withdrawal of the bursary in England, alongside more supported funding models such as full fee payment with the bursary, makes nursing a much less appealing choice for this demographic.

Other occupations where there are shortages, such as teaching, have successfully used financial incentives, such as paying university fees, to recruit. Importantly, this rewards individuals for studying – and they do not become an employee while they are training.

To attract nursing students, we need to look at a variety of different options, including loan forgiveness schemes (where when certain criteria are met, all or part of an educational loan will be cancelled) and post-graduate training. 

Low pay for on-the-job training is reflective of recent government policy, which appears to be about having the most hands for the least money. It may well provide a low-cost solution to a staffing crisis, but it is unlikely to provide better care for patients, or longer-term job satisfaction.

Ultimately, the key question is: do we really want to risk all we have gained as a profession to return to the days when we were poorly rewarded, potentially exploited and largely voiceless?

We need to carefully consider exactly what we are giving up. For me, it is a poor exchange.

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Alison Leary is professor of healthcare and workforce modelling at London South Bank University



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