In 2017 the bursary for student nurses in England was removed in an effort by the Government to reduce the cap on places and boost recruitment to undergraduate nursing programmes. Under this new model the savings from the bursary and cost of living loans would be directed into healthcare delivery and, with funding no longer a limitation to the number of places available, it was predicted that recruitment would increase by 10 000 student nurses by 2020 (Health Education England (HEE), 2016).
Sadly these predictions did not come to pass. Applications to nursing programmes in England have fallen by 32% since the removal of the bursary was announced (UCAS, 2019). There are fewer 18-year-olds in the general population (Office for National Statistics, 2019), which has a direct impact. We have also witnessed diminishing numbers of applications from those who historically brought a wide range of professional as well as life experience to a profession that requires advanced communication skills, emotional resilience, intellectual capacity and physical stamina: the mature student. In 2016 the average age of a student nurse at entry was 29. UCAS (2019) figures indicate that the number of applicants over the age of 20 has dropped by 40%. These factors have a significant impact on recruitment to nursing and yet, they seem to have been largely discounted by the decision makers.
Wales kept the bursary in place and Scotland decided to not only keep it, but to increase it (Scottish Government, 2018). The devolved nations have not experienced the same drop in recruitment as England, with Scotland in particular experiencing an increase. Can the drop in recruitment we have witnessed in England be anything other than a response to the expectation that the majority of the financial burden for nurse education now falls heavily on the shoulders of the individual student?
I attended a conference shortly after the bursary removal was announced in 2015. A representative from HEE had been asked to speak about the future of nurse recruitment. Her argument, in favour of the change, was that modern university applicants expect to accrue debt from student and other loans, and this is a normal part of the experience of higher education for the average student. She was right of course—for the average student entering higher education at 18, enrolled on a course for which the workload is nowhere near the 40 hours a week expected from student nurses, where the opportunity to secure additional employment is helped by not being expected to juggle shifts on clinical placement with late finishes, early starts, nights and weekends. Sadly, what the HEE speaker failed to appreciate was that nursing students are not representative of the average student population. The nursing profession has historically attracted young people (predominantly women) from working class backgrounds whose parents are less likely to be in a position to offer financial support. This is a demographic who may not feel comfortable with accruing debt that they will be repaying for a number of years. A mature student who is attracted to the nursing profession is also likely to have caring responsibilities for children or elderly relatives, making it even more difficult to find additional employment to supplement their income. They may have a mortgage and a range of other commitments that they could possibly manage with the help of a bursary, but which make the additional burden of a £30 000 student loan an overwhelming prospect.
Although the 3-year undergraduate programme is by no means the only route to nursing, it is currently the one that can deliver high quality as well as high scale. We are in a nurse recruitment crisis. Overseas recruitment and fast-track undergraduate and postgraduate routes to nursing have so far yielded moderate results and had a limited impact on recruitment overall. The most effective way to manage this crisis is to develop a funding model for student nurses that remunerates them relative to the work and commitment that is expected of them. We have evidence from Scotland and Wales that this has impact. Nurses are the connective tissue of our health service. Increasing recruitment is a silver bullet for improving all measures of patient safety and experience and needs to be addressed through proper investment as a matter of priority before our healthcare system and the nursing profession is damaged beyond repair.