Attrition in student nursing refers to the number of students who do not complete their nurse training (Hamshire et al, 2019). Attrition from pre-registration nursing programmes is a concern for higher education institutions (HEIs), which negatively affects income and student experience (Lovegrove, 2018). The Health Foundation (2019) put the average attrition rate for UK pre-registration nursing students at 24%, with that in the North West region at 21%. Health Education England published the Reducing Pre-registration Attrition and Improving Retention (RePAIR) study, which identified the 10 main reasons why nursing students interrupt or discontinue their studies, with financial reasons being the most prevalent in that research (Lovegrove, 2018).
At the author's HEI at the time this research project took place there were 157 pre-registration nursing students on interrupted studies. Approximately 75% of these students could have resumed studies in time to have joined the Nursing and Midwifery Council (NMC) register by March 2024, supporting the 50 000 nursing expansion programme (Department of Health and Social Care, 2022). A challenge for HEIs and the future of the NHS workforce is that not all students return from interruption. When these students do return, they may struggle to pick up the pace of academic work and integrate into a new cohort of students (Handwerker, 2018). This research aimed to examine the reasons why students suspended their training and what measures they thought would help them to successfully complete the course.
Aims
The aims of this study were to examine the reasons why pre-registration student nurses interrupt their studies and consider ways to enable them to return and succeed in completing the course.
Literature review
Before commencing the study, a literature review was undertaken to understand what was known about the issue. Wray et al (2012) undertook a retrospective cohort study to identify the factors affecting progression from year 1 to year 2. This study was based in the North of England so its findings may, arguably, be similar to the characteristics of the student population in the present author's HEI. Study findings suggested that younger, traditional entry students were more likely to withdraw than non-traditional older students. Wright and Wray (2012) supported this finding: in their research, younger nurses left mostly within their first year of study, often citing that the role of the nurse in clinical placements was not what they had expected.
DeWitty and Byrd (2021) explored the recruitment and retention of under-represented, first-generation and ethnically diverse students within their student nurse population. They noted that these students often had additional academic and social challenges, that if left unaddressed would negatively affect retention. Jean-Baptiste (2019) and Ooms et al (2013) also highlighted the specific needs of non-traditional students, which included needs for additional numeracy and literacy support alongside pastoral support. Tranter et al (2018) undertook an integrative review of initiatives aimed at retaining minority students and found that the provision of both academic and pastoral support demonstrated better student outcomes.
Eick et al (2012) carried out a systematic review of placement-related attrition. In their summary, perceptions of the profession, workplace acceptance and placement support were seen to have a direct effect on student decisions to leave the course. Stress was identified as another factor in this review. Mills et al (2020) examined 100 first-year nursing student narratives for themes, noting that stress was mentioned by almost all respondents. For these students trying to juggle various demands, and academic, social and financial pressures added to their poor mental health. Galvin et al (2015) looked specifically at mental health field student nurses' experiences of stress during their training. They found that younger students were more likely to report feelings of stress, along with academic demands and placement culture.
Hamshire et al (2019) identifed three key themes affecting attrition – personal circumstances, workload pressure and clinical placement culture – suggesting that attrition is a systems problem requiring a multifaceted approach. Gaining a better understanding of these factors and tailoring support to interrupted/returning students may enable successful course completion for returning students and reduce attrition.
Methods
Study design
This was a qualitative research project consisting of a pre-interview scoping questionnaire and one-to-one semi-structured interview.
Qualitative research methods have their philosophical roots in a constructivist medium favouring a collaborative approach with participants (Safdar et al, 2016). When conducting qualitative research, it is important to consider the methodology of best fit for the project. Semi-structured interviews present as a natural conversation with the potential to gain more genuine responses (Maltby et al, 2010). This methodology was chosen because it held the potential to provide the richest data.
Ethical approval for the study was obtained from the HEI Ethics committee (unique reference number HEALTH 0332)
Participants
Eligible participants were interrupted BSc pre-registration adult, mental health, or child field nursing students due to return in semester 1 of the 2022/23 academic year, within 4 months of the time when the study took place. Students identified as meeting these inclusion criteria (n=95) were contacted via individual email with an invitation to participate in the research.
Data collection and analysis
A link to an anonymous online questionnaire (using MS Forms) was sent out to all eligible students to better understand their reasons for suspending their course and to invite them to be interviewed. Individual semi-structured interviews were conducted with consenting students. Interviews took place via Microsoft Teams using the recording and transcription option. These were then checked by the researcher for accuracy and kept in a secure password-protected file.
Thematic analysis was undertaken using the Braun and Clarke (2006) six-step inductive thematic analysis process by the lead researcher, with input from the project lead and quality lead for this study. Transcripts were read several times and open coding identifying meaningful quotes took place. These codes were then merged into categories to identify key themes within the evidence.
Recruitment
The response to the invitations sent to students was low, which could be attributed to the likelihood that they were not accessing university emails while interrupted. The invitation was also sent to personal email accounts where provided. The questionnaire was completed by 14 students of whom 9 agreed to be identified and undertake individual interview. The remaining 5 participants declined the invitation for an interview but agreed to their comments being used for this study. Email reminders were sent weekly to eligible students until at the point where the researcher needed to move on.
Findings
Themes emerging from questionnaire
Three of the five anonymous respondents who declined interview (A1-5) cited mental health issues as their reason to interrupt study. Of the nine students who agreed to be interviewed (S1-9), four cited poor mental health as the primary reason. One student (S1) cited a mixture of COVID-19 and mental health. Therefore poor mental health was either solely or partially behind 8 of the 14 students' reasons for suspending studies, making it the most prominent causative factor. Other responses are shown in Box 1. Qualitative comments from the anonymous questionnaire can be seen below.
‘My mental health was getting worse, and I just felt incredibly burnt out’
‘I was diagnosed with acute anxiety order [disorder], which at the time had a major impact on the most basic of my activities of daily living, and my ability to function’
Reasons given in questionnaire responses (n=14) for suspending course
When asked what the students thought would help them return to their courses successfully, a need for support from both academic and pastoral sources was identified:
‘Some support on academic writing and how to set out assignments etc would be helpful as I haven't done it for a year’
‘Support relating to health - time for appointments, help to avoid illness, understanding when off due to health’
Qualitative semi-structured interview themes
Following completion of the questionnaire, nine students agreed to be interviewed. To ensure anonymity, the participants were given letter and number identifiers (Table 1). Comments from student participants can be seen below.
| Student participant | Field of study | Length of interruption | Reason for interruption |
|---|---|---|---|
| S1 | Adult | 2 years | COVID-19 + mental health |
| S2 | Adult | 1 year | Physical health + COVID-19 |
| S3 | Adult | 1 year | Mental health |
| S4 | Mental health | 1 year | Family illness/caring responsibility |
| S5 | Mental health | 2 years |
Physical health |
| S6 | Adult | 1 year | Academic failure + stress |
| S7 | Adult | 1 year | Mental health |
| S8 | Child | 1 year | Mental health |
| S9 | Adult | 1 year | Mental health |
Perceptions, belonging and uncertainty
When discussing interruption, the students had differing experiences of the process. Those interrupting for health reasons seemed at ease with the decision:
‘We did discuss the, like, different routes and stuff. I think this was generally the best thing for me’
‘My mental health was getting really bad at that point, and I just felt really burnt out, and I just needed some time’
Validity of the decision to interrupt was also questioned by some students.
‘At times I felt like I was just being a bit, you know, dramatic. I should not have, like, wasted the year’
Uncertainty about the length of interruption needed caused some students with an unsure diagnosis to express concern. Two of the participants had interruptions for longer than the usual 12 months. This led to them voicing concern about returning after such a long break.
‘Nervous, I am, yes. I have had, like, 2 years off, so it is a big step coming back’
‘I have been off for two years, eight months. It has been a long time and all that apprehension just because it had been that long’
Despite this, there were several students who expressed feeling positive about their return to study.
‘I am excited. There are so many things I want to do’
‘Yeah, I think I am looking forward to it’
‘I feel refreshed, and I am going in with this new mindset that, like, I can do it. Or as [whereas] before I was like, I do not think I can do it, I cannot get through this year, things like that’
The theme of support academically and with integration into a new peer group featured in both the questionnaire responses and the interviews.
‘I think I'd benefit from some help with the academic side… going over, like, how to format assignments and things like that’
“The only thing I suppose … the [thing] I haven't got now that I had before was the peer group’
‘I'm not going to know anyone’
‘I'm a bit anxious about people already having their little groups, feeling a bit like an outsider, I suppose’
Some students had stayed connected with members of their previous peer group, but this evoked some strong feelings.
‘It just upsets me that I could not be part of it … and they will all be graduating without me. But that is as it [is], isn't it?’
Visualisation and experience for future practice
Students were asked how they felt about returning to clinical placements. Two students had been able to maintain clinical contact by working as healthcare assistants while interrupted. This led them to not feel disconnected from practice.
‘I have done more. Uh, you know, feel more attached to practice because I have done more hours' work because I was able to’
Others for health reasons were unable to maintain clinical links while interrupted.
‘I've not done any work since COVID’
The effect that COVID-19 had on the participants was evident for those with long-term health issues or living with vulnerable people because they could not go on to practice placements or work in health care while their studies were interrupted.
Students were asked how they visualised themselves as nurses and their aspirations for the future. Some were undecided and were simply trying to get to the end of the course.
‘Not really, I'm hoping I can finish the year at the moment and, fingers crossed, the course’
‘I can visualise myself during the job. Uh, but what in what area? I am keeping an open mind’
Some students had formed firm ideas of where they wanted to be as a nurse.
‘I just want to qualify and be a good nurse’
‘I think I want to be someone who's there for their patients and taking good care of them and doing the best they can to get vulnerable people well again’
‘A health visitor, since I've had my little boy [it has] sort of changed my outlook a little bit’
Student ideas for improving the interruption/return to study experience
Students were asked to reflect on their experience of interruption and give ideas of how they felt the process could be improved for future students. Many had a positive experience of the process. Some students felt overwhelmed with the return process currently followed at the HEI. Specifically, there were issues identified with enrolment.
‘I found the return and enrolment process quite stressful’
‘Enrolment issues/information needs clarity.’
Other ideas included a refresher session for clinical skills (S3), having a ‘buddy’ system for returners (S6), or holding a workshop for returners where all the different processes involved in returning are dealt with together (S8).
Discussion
From the interviews and existing literature, the reasons for a student needing a formal interruption of study are multifactorial (Hamshire et al, 2019). Mental and/or physical health are the most common reasons stated for the need to take a break, often exacerbated by the pressures of the course. This warrants exploration of how students can be best supported to manage their health while on the programme. Mills et al (2020) examined the specific needs of first-year students as they learn to juggle the demands of the course alongside personal circumstances. They recommend that providers review their support systems alongside student engagement to maximise their effectiveness and potentially reduce year 1 attrition.
The continued impact of COVID-19 on some students at the time of the research was clear. Students voiced fears regarding their own health and health risks for vulnerable loved ones. Nursing student's disclosure of feeling stressed and overwhelmed due to COVID were among the major concerns relating to attrition, as highlighted by Health Education England (2020). Griffin and Riley (2022) found that all participants highlighted stress due to COVID-19 as causing increased workloads and emotional distress. COVID-19 presented a severe challenge within all areas of healthcare provision and the effects are still being felt. Griffin and Riley (2022) recommended that HEIs should include the recognition of psychological distress within pre-registration programmes and encourage students to seek support.
Bak et al (2020) argued that the current content-laden nursing curriculum leaves no space to address the mental and physical health of nursing students. Recent changes to the NMC (2023) pre-registration nurse education standards recommend students take responsibility for their own health, through being empowered and supported across all course provision. As HEIs look to update their curricula, it is vital that students' physical and mental wellbeing is supported.
Peer support and anxieties about losing peers and having to find new ones on return to study were identified by students. Recommendations from Wray et al (2012) included the use of social networks to address student isolation. The introduction of a returning student's peer social group may help these students integrate. The sense of ‘belonging’ to a peer group and feeling comfortable in that group was reported by the student participants. This ‘belonging’ can be hampered further for students who are returning directly to clinical placement because they will not meet their new peers in person prior to return. Blake et al (2022) made several recommendations following their study ‘Building belonging in HE’ aimed at improving the student sense of belonging and inclusion.
Wray et al (2012) identified factors influencing attrition, arguing that HEIs need to improve the quality of their personal and academic support. Health Education England (2020) also reported that a high percentage of students cited a lack of HEI support as a factor when considering leaving the course. Since this research project was started, Health Education England (2022) has published a good practice guide for HEIs, which will be used alongside this research to make improvements to the support system for interrupted/returning students in the author's institution.
Strengths and limitations
The strengths of this study include it being primary research. It has identified some issues faced by students at one HEI based in the North West of England.
The study limitations include the small response rate to the scoping questionnaire (n=14), which could mean that the findings are not representative. Some of the student interviews (n=9) unearthed significant issues and it could be argued that these students agreed to be interviewed because they had their own agenda. This in turn may affect the generalisability of the findings.
Recommendations for practice
In response to the findings presented here and in the other resources identifed, the HEI in question intends to introduce an improved student support package, including the following:
Conclusion
The reasons why pre-registration nursing students decide to interrupt their studies are multifactorial. Ensuring that HEIs havein place tailored support for the return to study for these students is vital to improve attrition and student experience. Findings from this research project and recent Health Education England (2022) good practice guidelines hold the potential to reduce nursing student interruption and attrition by implementing support prior to interruption, during interruption and on return to study. The author's HEI will use the findings from the research study and the good practice guidelines to introduce a comprehensive support package for its students.