Both major political parties promised to restore student nurse funding in their election manifestos. Shortly after winning the election, the Conservative Government announced that it was to reinstate the bursary for student nurses in the guise of a maintenance grant. These grants, to the value of £5000–8000, will be given to students starting nursing courses in September 2020 (Campbell, 2019).
Background
There have been many news headlines over recent years highlighting the workforce issues facing the NHS. Perhaps the greatest challenge is rectifying the acute shortage of trained nurses, which The King's Fund has reported (Beech et al, 2019), based on figures from NHS Improvement (2018). Nurse vacancies soared to a high of around 41 000 in 2018, with nearly 1 in 8 posts being unfilled. The King's Fund suggested that this level of vacancies may worsen and attributed this to the potential aftermath of the UK leaving the EU, with data being cited showing that European-trained nurses are leaving the UK to seek work elsewhere (Beech et al, 2019).
Nurse recruitment problems
It would be convenient to blame the problem of nurse recruitment on a single element, but the truth of the matter is so much more complex. In reality, before the ink was even dry on the Nurses' Bill, which received its royal assent in 1919 with a mandate to create a General Nursing Council (GNC) for England, Wales, Scotland and Northern Ireland, there was a shortage of nurses (Glasper and Carpenter, 2019). The problem of capacity has haunted the nursing profession ever since. The creation of the enrolled nurse role in the mid-20th century and later the nursing associate in the second decade of the 21st century were attempts to boost the supply of educated nursing support workers. Enabling healthcare assistants to join the nursing profession only kicked the can down the road, and this new government can no longer procrastinate on how to increase the number of NHS nurses.
For years successive governments have relied on overseas recruitment to ease the burden of nurse shortages, especially with recruitment from the EU. However, given the changing healthcare demographics, with an increasingly elderly population with long-term conditions, even this strategy has proved inadequate to meet the demand for nurses. This situation was exacerbated by cuts to student nursing commissions by Health Education England. The scale of disinvestment in nurse education in England was discussed at the Royal College of Nursing (RCN) Congress in May 2017. During one of the debates, it was revealed that investment in education and training had been subject to reductions of up to 45% in England (Glasper, 2017). Since then the RCN (2020) has been campaigning for mandatory standards for nurse staffing levels and skill mix standards.
The situation was aggravated by the decision of the Government to abolish the student nurse bursary in England in 2015. England was the only country in the UK to do so, with Northern Ireland, Scotland and Wales retaining a bursary-funded model to underwrite the costs of pre-registration nurse education. The thinking behind this decision was that the abolition of the non-means-tested bursary and its replacement with a student loan would lead to an increase in those applying to undertake nursing degrees in English universities. This was because Health Education England funded the bursary scheme and therefore placed limitations on the number of student nurses universities could accept for each of the four fields of practice.
It was believed that lifting the cap on student nurse numbers by replacing the bursary with a student loan would allow more people to apply for undergraduate nursing courses. This decision was embraced by the Council of Deans, which represents the university nursing studies departments.
However, this decision led to a significant fall in the number of applications to undertake a nursing degree. In the aftermath of this decision, data from a report by The King's Fund revealed that the number of student nurses accepted on to English university degree courses in 2018 was 4% lower than in 2016 (Beech et al, 2019:6).
Why did student nurse recruitment collapse, given that all other undergraduates take out loans to pay for their tuition fees? It should be remembered that the vast majority of UK university undergraduates are school or college leavers. Conversely, many nursing students—up until the abolition of the bursary—were mature students.
Concerns were expressed, at the time of the abolition of the bursary in 2017, that it would potentially lead to a significant drop in the recruitment of mature nursing students, who make up 50% of student cohorts in certain fields of practice such as leaning disability and mental health nursing.
The Office for Students, a non-departmental public body of the Department for Education, recently commissioned research to shed light on the effect of the abolition of the bursary on mature-entry nursing students. This research cites data from 2017/18, which shows the number of mature student enrolments to undergraduate nursing, midwifery and allied health profession programmes fell by 15.2% in the six universities who responded to the research request, and that this reduction in applicants was linked to the change in funding (Office for Students, 2019).
Recruitment strategies
There are currently four educational routes leading to registration as a nurse in England:
School or college leavers entering nursing courses appear to have fewer concerns about student debt than older mature students. The full-time nursing undergraduates following a traditional 3-year degree course in an English university will typically pay £9250 per year in tuition fees and a similar amount on accommodation and subsistence costs. This can amount to nearly £60 000 or more over a 3-year period for some students without financial help from their families.
Given this significant cost, it is easy to see why mature students have begun to embrace the slower but less financially painful route of commencing their careers as healthcare assistants and then progressing either as a trainee nursing associate or via an apprenticeship scheme to nursing registration (Department of Health and Social Care, 2016).
Nursing associate courses are also part of the NHS modern apprenticeship schemes. Importantly for debt-averse mature students, often with families to support, the cost of the apprenticeship will be paid by their employing NHS trust. Nursing apprentices are treated as employees and are paid a wage for the duration of the course and are entitled to an occupational pension.
Government aspirations
In June 2019, NHS Improvement launched the Interim NHS People Plan to address staff shortages (NHS Improvement, 2019), which aims to ensure that the NHS Long Term Plan, which sets out the Government's 10-year vision for health care in England, does not get derailed by staff shortages (NHS England and Improvement, 2019).
The role of nurse staffing in maintaining patient safety has been recognised in the safe staffing guidelines for adult hospital wards produced by the National Institute for Health and Care Excellence (2014).
Underpinning this emphasis on safe staffing is research by Rafferty et al (2007), which showed that hospitals with the highest patient-to-nurse ratios had a 26% higher mortality. Similarly, Griffiths et al (2018) showed that low registered nurse staffing is associated with reports of missed nursing care.
The Government knows that it needs to tackle nurse retention as a matter of priority and is encouraging trusts to take steps to do so. In areas experiencing acute staff shortages, such as mental health or learning disability, students will be entitled to an extra £3000 in addition to their grant.
Student nurse attrition
Another factor that needs to be addressed as a matter of some urgency is the unacceptable levels of student nurse attrition. Research in 2018 found that up to 25% of students failed to complete their nursing degrees (RCN, 2018).
A study conducted in Northern Ireland by O'Donnell (2011) investigated why student nurses gave up their studies voluntarily. This research showed that a significant number of these ex-students had a prior expectation that their nursing degree course would be primarily vocational in nature and less academic than it actually was. Clearly this aspect of nurse education needs to be more clearly addressed both at interview and through enhanced pre-course information.
Conclusion
Nurses are one of the NHS's most valuable assets and how the Government invests in their training and subsequently nurtures their ongoing development will ultimately determine the future of the NHS. It is hoped that the expansion of routes into nursing and the new funding arrangements for training will help in this quest to attract greater numbers.