The nursing profession in the UK faces significant challenges, with students interrupting their studies for various reasons, impacting their academic progression and career development. Factors contributing to these interruptions include financial difficulties, academic struggles, personal circumstances, and mental health issues (Council of Deans of Health, 2023; UCAS, 2023a). This article presents an innovative project designed to support nursing students in the UK whose education had been interrupted, entitled ‘Supporting Interrupted Nursing Students to Return to Programme’. This initiative, comprising a 6-week summer school held between May and July 2022 at Northumbria University, focused on pastoral support to re-engage students with their nursing programmes. Through a range of activities, including wellbeing and resilience workshops, art-based projects and skills-development sessions, the project sought to address the complex factors contributing to study interruptions. This innovative approach highlights the importance of comprehensive, individualised support in aiding nursing students to return to education.
Background
UCAS released data in December 2023, showing a mix of trends within the UK's higher education nursing sector. A total of 48625 students applied for nursing courses, reflecting a complex picture of fluctuating interest post pandemic (Council of Deans of Health, 2023; UCAS, 2023a). Although there has been a 13.4% decrease from the heightened numbers witnessed during the pandemic, these figures remain 9.7% above pre-pandemic levels. This suggests a sustained, if somewhat moderated, interest in nursing as a career.
The initial surge in applications during the pandemic can be attributed to the heightened visibility of the nursing profession and the public's admiration for healthcare workers' efforts during a global crisis. However, this trend has reversed, with applications declining significantly in 2023. This decline is attributed to several factors, including the perceived financial and emotional toll taken on those in the profession, which was exacerbated during the pandemic (Iddrisu et al, 2023).
Furthermore, according to UCAS there was a significant rise in the number of students disclosing a mental health condition, with the figure reaching 36000, up from 22000 the previous year – a 63.6% increase (UCAS, 2023b). This is more than double the 16000 reported in 2019, representing a 125% increase. This rise may be attributed to the heightened stress and adversity experienced during the fluctuating world economy and the psychological toll of COVID-19 on healthcare workers and students (Davey et al, 2022; Iddrisu et al, 2023).
Of the applicants, 26330 were successfully accepted on to undergraduate nursing courses, marking a 10.6% decrease from the previous year. Despite this decline, the proportion of accepted applicants has increased to 54.1%, indicating a more competitive landscape and potentially a higher calibre of students. The distribution of acceptances varied across different types of institutions, with lower, medium, and higher tariff providers accepting 15025, 8795, and 2510 students respectively. Lower tariff providers typically have fewer entry requirements, while higher tariff providers have more stringent entry criteria (UCAS, 2023a).
The decline in applications from all age groups, particularly among 25–29-year-olds and 18-year-olds, is concerning (Hill, 2023). It suggests that nursing may be losing its appeal for both traditional school leavers and those seeking a mid-career change. The reasons behind this trend are multifaceted, ranging from the challenges and stresses of the job to the financial implications of studying. Addressing these perceptions and realities is crucial to ensuring a steady influx of passionate and dedicated individuals into nursing (Ford, 2023; UCAS, 2023a).
Higher education institutions (HEIs) in the UK have a vital role in supporting nursing students whose studies had been interrupted and devising innovative strategies to facilitate their re-entry into nursing programmes. Health Education England (HEE), in conjunction with the Reducing Pre-registration Attrition and Improving Retention (RePAIR) project, played a critical role in addressing the issue of student nurse attrition, which remained a pressing concern for the UK's healthcare system (HEE, 2018). High attrition rates contribute to nursing workforce shortages, ultimately impacting the quality of patient care. By fostering collaborative partnerships with HEIs, the HEE enterprise facilitated the development of innovative strategies to support interrupted students and improve retention, thus addressing the pressing issue of nurse shortages in the UK (HEE, 2018).
In addition, the RePAIR project has emerged as a strategic initiative focusing on identifying and addressing the root causes of attrition and enhancing the retention of nursing students. According to the RePAIR report (HEE, 2018), 96% of students agreed that they had made the right decision in enrolling on their course. However, the study identified several critical factors that, if unaddressed, could affect the supply of newly qualified practitioners. These factors include pressures relating to income, student confidence levels, and the significant role of the clinical component of a course, which is heavily influenced by the clinical supervisor (practice assessor or mentor) and the culture in that clinical setting.
In the UK, the issue of nursing students leaving their programmes before completing their degrees has become a significant concern. Recent data shows that approximately 25% of nursing students drop out before graduation, which exacerbates the ongoing nursing shortage in the NHS (Health Foundation, 2018). Various factors contribute to this attrition, including financial difficulties, academic pressures, and negative experiences during clinical placements. These challenges highlight the need for improved support systems to help retain students and ensure they complete their training, which is crucial for addressing the shortage of qualified nurses in the UK (Health Foundation, 2018).
Nursing students whose studies have been interrupted face significant challenges in returning to their courses, including navigating the complexities of the education system, managing their finances, and addressing underlying mental health concerns. Research has shown that mental health issues are a leading cause of interruption among nursing students, with many experiencing poor mental health and wellbeing during their studies (HEE, 2018). The academic demands of nursing programmes, coupled with the pressures of clinical placements and long working hours, can take a toll on students' mental health (HEE, 2018). Students may also face personal stressors, such as relationship breakdowns, which further exacerbate their mental health challenges. Moreover, interrupted nursing students often face difficulties in returning to their studies and completing their degree, resulting in a significant loss of human resources and nursing scarcity (HEE, 2018).
The RePAIR report (HEE, 2018) sets out recommendations for system-wide improvements to enhance retention including:
These strategies aim to address the factors that can, if ignored, lead to the interruption of nursing studies by failing to ensure that students are well-supported throughout their educational journey.
Evaluation process components
The evaluation process for the support programme for interrupted nursing students at Northumbria University was designed to ensure that it was comprehensive, robust and effective in addressing the students' needs. This comprised several key components:
These themes informed the ongoing development and refinement of the support programme, allowing for the tailoring of support services to address the unique challenges faced by the nursing students who had interrupted their studies. The support services provided included mental health support, academic assistance, and other resources. The programme's effectiveness was regularly monitored, enabling continuous improvement and adaptation to better meet the changing needs of the nursing students over time. This iterative approach ensured the support programme remained responsive and effective in facilitating the return of the nursing students who had interrupted their studies.
The innovation project
The 6-week summer returners programme running at Northumbria University was designed to comprehensively support nursing students resuming their studies. Although attendance was encouraged for all sessions, it was not mandatory, resulting in varying levels of participation. The programme proved to be effective in addressing the diverse needs of the students, although some sessions were better attended than others.
The programme started with an introduction to outline goals and expectations. Sessions on academic regulations for taught awards (ARTA) kept students updated on academic policies. Information on student support services provided guidance on managing interruptions and the return process, including ensuring students had their Disclosure and Barring Service (DBS) checks, mandatory training, effective communication skills for re-entry, and access to the 24/7 Ask 4 help desk.
The change-of-circumstances information and process session provided guidance on administrative re-enrolment procedures. Action learning sets and SMART planning workshops helped students set realistic goals and collaborate effectively.
To prepare students academically, workshops on academic levels and preparation were held. Mental health and resilience were addressed in wellbeing skills and resilience workshops where students explored their understanding of nursing. These were run by ReCoCo, a peer-led mental health education and support service in Newcastle. Creative expression was encouraged in the art and pottery workshop at Chilli Studios, a charity that aims to improve mental health and wellbeing through creative arts. GemArts Bollywood dance workshops fostered professional identity and cultural enrichment. Practical skills were covered in clinical skills (SkillsFest) workshops, which included nursing skills, simulation, and virtual reality. Study skills workshops enhanced academic techniques, and the Graduate Futures seminar provided career-planning insights.
Interactive programme leader questions and answers and placement discussions allowed direct engagement with academic and placement colleagues. The programme concluded with group evaluations and feedback, enabling students to reflect on their experiences and provide suggestions for improvement.
It was noted that many students engaged more with the student engagement team and project leaders rather than attending all the offered classes. This flexible approach allowed the programme to meet each student's unique needs and requirements for returning to their studies. Overall, this structured approach gave an opportunity for the nursing students to engage and become better prepared to return to the nursing programme.
Findings
Student engagement teams supported data collection. Data were retrieved from the students' university portals, where they selected their reasons for interruption or withdrawal from their programme based on a set of options (Table 1). This was followed up with small focus groups and some email communication. When this project commenced, there were 135 nursing students facing interrupted studies. From the evaluation of the return rate in September and January, it was found that 67 interrupted students had successfully resumed their nursing programme, indicating the project met its primary objective. The most effective activity was SkillsFest, offering students an opportunity to develop their clinical skills as mapped to their Nursing Midwifery Council (NMC) proficiencies.
| Reasons for leaving | Number of student |
|---|---|
| Financial | 9 |
| Academic challenges | 8 |
| Personal circumstances (family, carer responsibilities) | 19 |
| Health reasons (mental, physical) | 94 |
| Other (wrong course, decided against nursing as a career) | 5 |
| Total | 135 |
Quantitative data revealed the initial causal factors for students leaving their programme (Table 1)and the enhancements in the students' mental health and wellbeing, academic self-efficacy, and overall satisfaction with the programme, demonstrating the project's positive impact on the returning students (Table 2).
| Year of study | Autumn 2022 | Autumn 2023 |
|---|---|---|
| Year 1 | 16 | 6 |
| Year 2 | 23 | 10 |
| Year 3 | 9 | 3 |
| Total | 48 | 19 |
Qualitative data revealed four key themes related to students' experiences and the effectiveness of the support programme.
Theme 1. Anticipation and fear
Anticipation and fear starkly capture the emotional turmoil nursing students often face when contemplating their return to the academic and clinical environment. This theme explores the apprehensions and concerns that preoccupy their thoughts:
‘I am very worried about returning to my nursing programme.’
‘I feel frightened about returning as it has been two years since I stepped off. It's a new curriculum.’
‘I am excited about practice but scared about the academic work as I failed some assignments last year. The new standards have made this programme a lot harder.’
‘I'm scared about returning to the clinical settings since COVID. It made me ill and affected my mental health.’
Theme 2. Making contact and reaching out
Making contact and reaching out emphasised the critical role of proactive communication and support from educational institutions in re-engaging interrupted nursing students:
‘Having the university reach out to me was just what I needed to think about returning.’
‘I was so happy when I was contacted about this initiative. I didn't know where to start.’
‘I was worried about what to do next, so just left it. Then I received a call.’
‘I needed my time off due to my health, but having someone to talk to who signposted me to the programme leaders and wellbeing teams was what I needed.’
Theme 3. Preparing for return
Preparing for return focused on the practical and psychological readiness of students as they approached re-entry into their nursing studies, highlighting the resources and strategies that build confidence and competence:
‘I loved the workshops. I came each week. This programme was excellent and very personable. This is what I needed.’
‘The clinical skills on this programme were exactly what I needed.’
‘We had a range of skills and simulated learning which prepared me for my return to practice.’
‘The academic writing workshop was excellent, and I have learnt so many skills to improve my year 3 assessments. I feel positive. I cannot wait to come back.’
Theme 4. Psychological wellbeing and the nursing student experience
This theme revealed the multifaceted nature of psychological wellbeing and its intertwining relevance to the educational and clinical experiences of nursing students, particularly in the context of the COVID-19 pandemic. Furthermore, the study findings in this theme point towards the distinct demands on nursing students who play a role not only as academic students but also as practising frontline professionals in the making:
‘Most of the people I have met left the course due to mental health during the COVID pandemic.’
‘I feel as though I am ready to return now. The university helped with my wellbeing and referred me to counselling. I just needed some time out to get life a little more normal.’
‘I don't think people understand the pressure of being a student nurse. Working as a nurse is hard enough, let alone not having money, studying and working without pay.’
‘It's difficult as we are always included in the numbers. As part of a programme of education, sometimes we work as support staff due to staffing shortages. Then we slip through the net and our PADs [practice assessment documents] are just left till the end. It's seen as normal. It impacts on our coping strategies.’
‘We work, we have placements each week, and we study. All this during a pandemic. This is the reason for me leaving, not nursing as a profession. The impact of nursing on the front line affects your mind massively.’
Collectively, these four themes highlight a fundamental truth about nursing education: students studying for a nursing degree face significant challenges that necessitate comprehensive support and empowerment. These supports are essential not only for their immediate wellbeing but also for their ability to remain in their programmes and ultimately complete their qualifications. The data underscore the necessity of providing encouragement and resources to help students navigate the demands of their studies and clinical placements, ensuring they have the resilience and motivation to continue to the end of their training and become qualified nurses.
Discussion
This study aimed to evaluate the effectiveness of an educational programme designed to support nursing students who had experienced academic interruptions. The findings enhanced the authors' understanding of the challenges these students face and the impact of the support programme, revealing four key themes.
Anticipation and fear
This theme highlighted the apprehension nursing students felt when contemplating their return to the programme. These concerns stemmed from various factors, including changes in the curriculum, the academic workload, and the unique challenges of re-integrating into clinical settings in the post-COVID-19 era (HEE, 2018; Savitsky et al, 2020). The necessity of providing targeted support and guidance to alleviate these anxieties was underscored by these findings. According to Tinto's (1993) theory on student retention, the integration of academic and social systems is crucial for student persistence. Providing a supportive environment that addresses these fears can significantly enhance student retention rates.
Making contact and reaching out
This second theme emphasised the critical importance of proactive communication from educational institutions. The academic team initiated personalised email and telephone outreach to each nursing student whose course had been interrupted. This deliberate and individualised approach became pivotal in motivating students to reconsider their academic journey and fostering a sense of connectivity and belonging. Such efforts were instrumental in encouraging students to re-engage with their studies and easing their transition back into the academic environment (Ahn and Davis, 2020; Rueda and Lowe Swift, 2023). The theory of ‘social presence’, which posits that personal interaction and connectedness can enhance learning outcomes (Sung and Mayer, 2019), supports this approach by highlighting the importance of creating a community of support for students.
Preparing for return
The third theme focused on how the educational programme prepared students to resume their studies confidently. Workshops and simulated learning experiences were key in enhancing students' clinical and academic skills, boosting their confidence and competence for their return (Olaussen et al, 2019). Providing extra-curricular resources and personalised learning strategies helped students feel supported both on and off campus. Vygotsky's (1978) theory of social constructivism, which emphasised the importance of social interaction and scaffolding in learning, underpins the value of these preparatory activities. By offering tailored support, educational institutions can help students build the necessary skills and resilience to succeed in their studies.
Psychological wellbeing and the nursing student experience
The fourth theme acknowledged the profound impact of the COVID-19 pandemic on nursing students' mental health. The findings stressed the importance of addressing health needs through services such as counselling and support groups (Lai et al, 2020). Understanding the unique pressures faced by student nurses, such as financial strain and academic responsibilities, is crucial. The psychological stress theory (Lazarus and Folkman, 1984) highlights the importance of coping strategies and social support in managing stress. The study's findings reinforce the need for robust mental health support systems to help students navigate these challenges effectively.
Dissemination of findings
The findings from the evaluation process were shared with HEE and university staff, and were also disseminated at the conference held by the NHS North East and North Cumbria Enabling Effective Learning Environments team. This dissemination of knowledge contributed to a broader understanding of the challenges faced by interrupted nursing students and informed future initiatives aimed at supporting this vulnerable student population. In 2023, the findings from the study were used to inform the basis of a further NHS England-funded project called: The WISE Room (Bruce, 2023).Additionally, the programme, as an innovative initiative, won the Outstanding Support for Students category at the Times Higher Education (THE) Awards 2023.
Challenges and enablers
The support programme encountered several challenges, one of which was the initial obstacle of establishing trust with the interrupted students, who can exhibit low self-confidence as a contributing factor to them leaving academia. To address this, the programme incorporated a combination of practical workshops, mental health support, and coaching strategies. Another challenge arose from the diverse needs of students based on the duration of their interruptions. However, the project effectively tackled these differences by employing feed-forward approaches (looking ahead to the next opportunity to perform and offering constructive guidance on how to improve) and further coaching strategies.
A significant enabler for the programme was the consistency of facilitators and the involvement of external organisations with expertise in mental health and wellbeing support. These factors encouraged the development of safe working relationships between students and facilitators and provided students with empathetic guidance tailored to their individual needs.
Additionally, the programme had a formative attendance structure, meaning that interrupted students were not required to attend and participation was voluntary. As a result, there were several students who attended, but not all of them participated in every workshop each week. Many interrupted students opted for email and telephone conversations to facilitate their return to the programme alongside this summer initiative. Consequently, it is unclear whether the scheduled innovative activities or the concurrent telephone and email support contributed more to the successful return to the programme rate. Nevertheless, the number of students returning in September and January programmes was deemed optimal.
Future focus
The rapidly changing global landscape presents new opportunities and challenges for the nursing profession. This HEE-funded project, although focused on a small section of the UK student nurse population, provided critical insights into the support needed for interrupted nursing students. By engaging students in co-design, co-production, and interdisciplinary collaboration, Northumbria University is preparing them to address future challenges in nursing training and practice. Following this study, 240 students and staff were involved in the design, implementation, trial, and evaluation of a novel multisensory support system to support academic, emotional, educational, and placement wellbeing (Bruce et al, 2024).
Conclusion
This innovative study evidenced the substantial efficacy of the RePAIR initiative in re-engaging UK nursing students who had paused their studies. Through specialised strategies encompassing skills development, mental health support, and personalised engagement, the importance of student-focused nursing education was highlighted. Recommendations for practice include implementing comprehensive support programmes in nurse education, focusing on mental health and academic skills; establishing mentorship and resilience-promoting practices in nursing practice; and advocating for supportive policies and enhanced mental health resources in nursing policy. These strategies are designed to be adaptive to student requirements, encouraging continuous learning and safeguarding wellbeing within student cohorts.