Quitting before they qualify: what’s behind the spike in nursing students dropping out?
Posted 27 August 2021 - 11:00
The pressures pushing nursing undergraduates to leave their degrees early – and how to combat them
- Numbers of nursing students leaving their degrees before graduation appear to have surged, although there is a lack of official data
- Reasons for dropping out are complex, but funding and upheaval of the COVID-19 pandemic likely to be important
- Non-completion of nursing degrees hampers efforts to increase nurse numbers, as well as representing the shattered dreams of individuals
Attrition rates on nursing degrees have soared, with one in three (33%) of students dropping out in 2020, figures obtained by Nursing Standard suggest.
Nursing workforce experts say the pandemic is partly to blame for the rise in attrition – up from 24% in 2019 – but that the government’s decision to scrap the NHS bursary for nursing students in England is a likely factor too.
They also warn that the surge in attrition, coupled with rising numbers of nurses leaving the profession and a high volume of vacancies, mean a government plan to boost the nursing workforce in England with 50,000 more nurses by 2025 does not look achievable.
Impact of the coronavirus pandemic
Nursing students starting degree courses in the 2017-18 academic year were among the first cohort to go through the tuition fees and loans system that replaced the NHS bursary.
‘Like other students the pandemic has been a tough context in which to thrive academically. But added to this, achieving the full number of clinical placement hours has been challenging’
Jane Ball, professor of nursing workforce, University of Southampton
The latest annual Nursing Standard investigation into undergraduate attrition found 35% of 12,016 nursing students who began three-year degrees in England in that first year without the bursary did not finish their studies on time, 2020.
Even assuming a proportion of those are merely deferring completion of their studies, it is clear there is a significant increase. The drop-out rate had been stable at 24-26% in the three consecutive years before that.
University of Southampton nursing workforce and policy professor Jane Ball says the pressures COVID-19 brought are likely to have affected students’ progress and attainment. Clinical placements were cancelled and lectures moved online.
‘The pandemic has been a double whammy for nursing students,’ says Professor Ball.
‘Like other students they have had a tough context in which to thrive academically. But added to this, achieving the full number of clinical placement hours – and making up lost hours – has been challenging.’
Legacy of nursing bursary’s removal
Had COVID-19 not caused upheaval to education last year, it might have been easier to measure the eventual impact abolition of the nursing bursary was to have on the freshers of 2017-18.
It seems likely it did have some effect though. Acceptance on to nursing programmes in England remained largely unchanged: in 2016 the figure was 22,040, the following year, 20,820. This was despite a 23% drop in applications, according to UCAS (Universities and Colleges Admissions Service).
This might suggest some shift in the make-up of the intake, and therefore its potential attrition rate.
‘The impact on the removal of the nursing bursary still runs deep and its return is the best way to reverse this trend in students leaving before they qualify’
Patricia Marquis, director, RCN England
‘We can’t say exactly how this higher acceptance rate will have changed the nursing student profile of this cohort, but it is likely to have changed it,’ Professor Ball added.
The rise in attrition is not confined to England, according to Nursing Standard data.
A similar pattern in Scotland, which like Northern Ireland and Wales retained nursing bursaries, suggests the pandemic – more than funding – was a key factor in student attrition.
Across the UK – what the data say
- A third of UK nursing students on recently-concluded three-year programmes left their studies before graduation – 33% of 16,827 in the 2017-18 cohort – Nursing Standard’s annual investigation found
- For three consecutive years prior to this, the overall figure was one in four (24-25%).
- Attrition rate was 35% in England, 31% in Scotland, 26% in Wales and 10% in Northern Ireland
Source: 61 UK universities responding to Nursing Standard data request (see box, bottom)
Flexible finishes for students who need to take time out
The body that represents the UK’s university faculties for nursing, the Council of Deans of Health, acknowledges the academic disruption caused by COVID-19 but says its members are not reporting higher numbers of students leaving studies. However, it did not provide data in support of this.
‘Our members report they have not seen an increase in non-continuation rates,’ says a spokesperson.
‘In part, this is due to a halo effect of the pandemic highlighting the national importance and value of healthcare careers.
‘Many final year students in 2019-20 were deployed into extended placements during spring 2020. Others, including vulnerable students, stepped away from practice learning for a time.’
The council uses the Office for Students definition of attrition, which it looks at whether a student has continued their studies after the end of their first year.
‘Most healthcare students who step off their programme return and complete their studies within a further 24 months,’ says a spokesperson. ‘Completion across a longer time period is still a success.
‘In enabling students to complete who may otherwise not, a flexible approach to programme length is positive for students, the workforce and patient care.’
Personal finance worries and a complex range of other factors
Aside from the pandemic, there are other reasons why a student might leave their course.
In 2018, training body Health Education England (HEE) asked more than 3,400 nursing students who had dropped out about their reasons for leaving.
Financial pressures were most commonly-cited, while other factors included academic, personal and clinical placement issues.
Given all this, RCN England director Patricia Marquis is certain the removal of the nursing bursary is a key factor.
‘The impact still runs deep and its return is the best way to reverse this trend in students leaving before they are able to qualify and join the nursing workforce.’
From September 2020, all nursing students in England became eligible for a £5,000 maintenance grant, with an incentive of a further £3,000 for those taking harder-to-fill mental health or learning disability nursing places, or in certain parts of England.
Investment in the current nurse workforce is investment in the future workforce
Ms Marquis says Nursing Standard’s figures are a clear demonstration that more needs to be done to retain students all the way to qualification.
‘It is also vital there is investment in the current workforce that is needed to educate and mentor students through to qualification.
‘Failure to do this not only puts patient care at risk but means students risk not completing their studies and entering the workforce.’
Can we all agree on a definition of student attrition?
In 2015, the Department of Health told HEE to halve student attrition in England, and the Reducing Pre-Registration attrition and Improving Retention (RePAIR) project was set up for this purpose.
The RePAIR report HEE published in 2018 recommended creating a standard definition of attrition across all healthcare programmes in England to aid workforce planning.
But three years on, no single definition has been accepted.
Last year, HEE told Nursing Standard it was working with the Higher Education Statistics Agency and Office for Students to align approaches to measuring attrition in England.
‘This increase in the UK’s nurse student drop-out rates is a huge concern – the pressures of the pandemic will have played a role but understanding their full impact will take longer’
Nihar Shembavnekar, economist, the Health Foundation
HEE chief nurse Mark Radford said at the time the latest estimate for attrition among nursing students due to complete courses in March 2021 was 16-19%, but declined to share the how the figure was arrived at.
This month, the training body declined to comment on whether that prediction had been borne out, nor would it share its own figures with Nursing Standard.
The agency did say, however, that just over 4% of nursing students had their training affected or delayed because of COVID-19.
HEE head of nursing and midwifery south east John Clark says: ‘The pandemic has inevitably had an impact on the total number of students qualifying at the expected time.
‘However, HEE, with practice and university partners, is working hard to ensure all students are able to return to their studies and given every opportunity to go on to achieve their potential.’
But Professor Ball is troubled by the lack of publicly available data on nursing student attrition.
‘It concerns me that this important data is not routinely collected and published,’ she says.
‘That Nursing Standard has to carry out this annual data analysis through Freedom of Information requests highlights a key gap in workforce intelligence.
‘The country’s healthcare system depends on having sufficient supply of nurses so it’s vital we know how many nurses we can expect to graduate each year.’
Would cutting the required clinical placement hours help?
Professor Ball says one of the solutions could lie in reducing the number of clinical placement hours that UK nursing students need to complete to pass their courses.
She points out that the Health Foundation flagged the need to address the long-term bottlenecks that limit nursing education capacity in a report last December. These included the relatively high number of clinical practice hours needed to join the Nursing and Midwifery Council register, compared to other countries.
Solutions suggested in the report include increasing the use of simulation-based clinical experience, or reducing the total clinical hours required – so that they are on a par with undergraduate courses in the US and Australia.
While the UK nursing regulator requires students to undergo 2,300 practice hours, this number is far higher than in other comparable countries. In Australia, the minimum is 800 hours, and in the US it is 868.
Professor Ball argues that the UK’s clinical placement hours requirement seems excessive.
‘Putting such emphasis on quantity of hours – as opposed to quality of learning experience – is a hangover from the days when students were counted in the numbers as part of the paid workforce rather than as supernumerary learners.
‘The high level of clinical placement hours required doesn’t just create local difficulties for finding clinical placements. It’s a pinch-point in the system nationally, limiting the country’s ability to increase the supply of nurses.’
An issue ripe for more research
Experts agree that more data and research to solve nursing student attrition are key.
The Health Foundation’s Research and Economic Analysis for the Long term (REAL) Centre team economist Nihar Shembavnekar says: ‘Better data and more research on the factors underlying this increase in nursing student attrition are much needed.
‘Results from the REAL Centre’s nurse supply model, due to be available later this year, will provide useful insights into the extent to which shifts might affect NHS nurse numbers in the long term.”
Mr Shembavnekar says registered nursing vacancies now account for almost a half of all NHS vacancies, and with risks to the inflow of nurses from abroad, it is crucial to secure the supply of nurses training in the UK.
‘In that context, this increase in the UK’s nurse student drop-out rates is a huge concern – the pressures of the pandemic will have played a role but understanding their full impact will take longer.’
Nursing Standard student attrition survey
Nursing Standard asked UK universities to provide start and completion data for nursing students who began three-year degree programmes in 2017-18 and were due to graduate in 2019-20 (or 2021 in cohorts that started in early 2018).
The data were collected through Freedom of Information requests emailed universities on 8 July 2021.
Of 85 universities offering nursing degree programmes approached for data, 45 universities in England, five in Wales, nine in Scotland and two in Northern Ireland responded with the requested figures.
Findings were analysed by Nursing Standard staff.
Teeside University, the University of the West of England (Bristol), the University of Gloucestershire, Birmingham City University consistently decline to share their data. The University of Exeter and University of East London and University of York also declined this year.
Nursing Standard has been collecting this information since 2006 and annually since 2017.
Further information
- Building the NHS nursing workforce in England : workforce pressure points – The Health Foundation
- Falling short: the NHS workforce challenge – The Health Foundation
- RePAIR project
- The Health’s Foundation’s REAL Centre
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