Blown off course
Midwifery student drop-out rates can be high, but why do some students fall away? And what interventions could make a difference? The RePAIR report is providing some answers, writes Juliette Astrup.
Student attrition exacts a financial, psychological and social cost. With the cost to the taxpayer of training a nurse at around £78,000 over three years (Health Education England (HEE), 2015), it causes a considerable financial burden to the system, not to mention a drain on the pool of qualified staff.
This is nothing new – student attrition in pre-registration clinical education is a long-standing problem that has been documented for decades (Orton, 2011).
But the need to tackle the issue has never been more pressing. Data from the Universities and Colleges Admissions Services (UCAS) shows a 30% reduction in the number of UK applicants to nursing programmes in England between 2014 and 2018 (UCAS, 2018).
The RCM has also revealed a 35% decrease in the number of applicants to midwifery programmes in England since 2013 (RCM, 2018).
In March 2015, the Department of Health (DH) published a refreshed mandate to HEE, which included a requirement to reduce unnecessary attrition and identify best practice in improving retention (DH, 2015). And so the Reducing Pre-registration Attrition and Improving Retention (RePAIR) project was born.
Covering the four fields in nursing – adult, child, learning disabilities and mental health – along with midwifery and therapeutic radiography, the project has involved universities and clinical placement providers, including 16 case study sites. Crucially, it has involved students, almost 3500 of whom responded to the RePAIR online survey. There were also 46 meetings to capture stakeholders’ opinions and experiences, and two workshops to share best practice.
The resulting report, published in October, paints a comprehensive picture of the factors impacting the student journey from pre-enrolment up to two years post-registration.
Alongside that is a toolkit containing learning materials and examples of best practice, and a costs calculator to help demonstrate the clear financial case for investing in student retention interventions.
The rate of attrition
Without a consistent, nationally agreed definition of attrition, HEE used a baseline of ‘pure attrition’ in the RePAIR study, defined as the proportion of students who did not complete on time within the standard pathway for that programme.
National data for students who completed in 2013-14 and 2014-15 showed that 33.4% of the pre-registration students included in RePAIR did not complete on time. Over the two years, the attrition rate for midwives specifically was 31%.
However, the evidence from the RePAIR case study sites, and feedback from members of the Council of Deans of Health, showed that many midwifery students – around 8.5% of them – experience an interruption but go on to complete their studies within two years.
Why do students leave?
While there were many positives to emerge from the study – for example, 97% of student survey respondents reported that they intend to pursue a career in their chosen profession within the next three years – it also identified a multitude of issues, such as inadequate course organisation, workloads, difficulties balancing the course with family life, lack of support, and poor mentorship.
Financial worries were by far the most significant concern, with many explaining how, without long holidays, they cannot earn enough to support themselves, leaving them increasingly in debt, or reluctantly dependent on others.
Academic worries were also very significant; many, particularly second-year students, said the shock of the relentless workload had led them to question whether they should stay on the course.
In all, two in five survey respondents (41%) acknowledged they had thought about leaving the course, and woven throughout the explanations why is the concept of feeling overwhelmed – by the combination of academic work and clinical placements, the level of responsibility, and the ramping up of academic expectations year on year.
We need more in place to support student midwives – they’re getting burnt out before they’ve even started
Particular pressure points identified include the second year, when workload leaps up but there is less support than in the first and third years, and the ‘flaky bridge’, when students experience a ‘confidence rollercoaster’ transition from their final year into practice.
Also drawn out in the report is the importance of managing students’ expectations from pre-enrolment, as there is evidence some are still starting their studies with a limited idea of what the course, or even the job, will really entail.
Carmel Lloyd, RCM head of education and learning, says that one of the key areas highlighted in the report in relation to the student midwife experience is the ‘first time in a clinical area, when how they are received and how frequently they have a good mentor is key’.
She adds: ‘The culture of an organisation is really important – how students are welcomed and supported when they first arrive, and how that continues over the next two to three years.’
Indeed, the RePAIR study consistently captures evidence of how important the clinical component of the course is to students. As the executive summary describes it: ‘The student experience, their desire to stay on the course, or indeed to consider applying to work in a service, is heavily influenced by the clinical supervisor (or mentor) and the culture in that clinical setting.’
Professor John Clark, regional chief nurse and head of allied health at HEE, and the lead on the RePAIR project, says that ‘broadly speaking, we haven’t heard anything new’ but this study, ‘the biggest dataset ever collected on the subject’, is still hugely significant.
‘It’s not always an easy message to hear,’ he adds. ‘Having this body of evidence means we are able to go back to the system and say: “This isn’t just a one-off experience. It’s having an impact on student attrition and retention and therefore we can do better.”’
This is certainly the hope of Deirbhile Murphy, a third-year midwifery student at Queen’s University Belfast, who says of the report: ‘It paints a grim picture – but it’s one that I recognise.’ ‘We’re expected to get on with it,’ she tells Midwives.
‘As though “this is just how it is - it’s meant to be this hard” – but I don’t think that’s the case.
‘I hope this report does change that. The evidence is there that there are underlying systemic problems, and things can be put in place to improve it.
‘We need more in place to support student midwives – they’re getting burnt out before they’ve even started. They don’t want to finish the training.’
RePAIR project recommendations
- National bodies should work together to create a standardised definition and measure of attrition.
- Higher education institutions (HEIs) and healthcare providers (HCPs) should work together to understand the cost-effectiveness of interventions to improve retention.
Step 1: Pre-enrolment 3
- HEE should address financial pressures by seeking ways to make hardship funds available to encourage more prospective students, particularly mature students, to embark on a career in nursing, midwifery or therapeutic radiography.
- HEIs should ensure clinical staff are actively involved in recruitment, and that prospective students really understand the career and the demands of the course to avoid making the wrong career choice.
Step 2: Duration of the course
- HEIs should review their approach to buddy schemes.
- HEIs and HCPs should work together to develop specific programmes of support for second-year students.
- HEIs should work more closely with their HCP partners to map out placement allocations for students throughout the duration of their course, and ensure students are reimbursed for costs in a timely way.
- HEE should work with HCPs and HEIs to ensure that HEE’s national strategy, to support students in clinical practice and their supervisors/mentors, is implemented.
- HCPs and HEIs should work together to resolve any dissonance around the students’ role in the clinical department and the interpretation of students’ supernumerary status.
- HEIs should work together to agree a national standardised approach to assessing students’ clinical competence, including a simple process of recording students’ prior clinical experience. Step 3: Flaky bridge
- HEIs should develop a clearer understanding of factors that affect student confidence levels, particularly at the point of progressing from student to newly qualified practitioner.
Step 4: Early clinical career
- HCPs should review preceptorship programmes, ideally in partnership with HEIs, to improve recruitment and retention of their newly qualified staff and ensure preceptors are appropriately trained.
- Neighbouring HCPs should work together with local education providers to agree a shared model of recruiting newly qualified practitioners.
- HCPs should gather data and seek to understand the impact on students’ early career choices of the culture of care in their clinical environments.
- HEE should seek to understand the relevance of the findings of RePAIR to the new models of pre-registration education and training that are being implemented in health and social care.
Toolkit and recommendations
Included in the RePAIR report are 15 recommendations that cover, among other things, better support for second-years, the need to map out placement allocations, and to be clear about their role when on clinical placements (see RePAIR project recommendations panel).
It also recommends the student ‘buddy system’, whereby students are paired up with more senior students who can offer advice and support.
Dr Sam Bassett, lead midwife for education at King’s College London, says they are already implementing a number of the initiatives suggested, including a buddy scheme, but she was interested in the practical applications outlined in the RePAIR case studies.
She says: ‘I like the idea of it being more specific; second-years helping first-years adapt to practice, and third-years helping first-years research the literature. The case studies provide some good ideas.’
Other initiatives in the toolkit range from ‘keeping warm’ videos for students pre-enrolment, to mindfulness and resilience training, to more personalised preceptorship programmes.
‘The recommendations are realistic,’ adds Carmel Lloyd. ‘There is no more money, so this is about what can realistically be done with the resources already in place. It focuses on areas of crisis, and what interventions you might try to support those students and get them through that.’
Top three reasons why... students have considered leaving the course
- Personal finances – little or no opportunity to earn money while studying, which can lead to debt
- Academic concerns – academic challenges, not knowing well in advance about practice placements and poor standard of lecturing
- Placement – negative clinical experiences, particularly in the first year.
Students have never considered leaving the course
- The end goal
- The personal ambition to be the chosen professional
- Support from family and friends.
Though not the summit of its ambition, at the very least the aim of the RePAIR project is to get people thinking and talking about student attrition and retention.
Professor Clark says: ‘I know for a lot of people it might make for uncomfortable reading, but I think it’s okay to be a bit uncomfortable – when we reflect on things which don’t go quite so well, that’s when we see a step change, that’s how we make improvement.
‘We hope that universities and placement providers continue to have that conversation.’
He adds: ‘For me, one of the critical things is that this isn’t about what universities can do better, or what practice placement providers can do better – this is about how they can work better together.’
Moving forward, regional chief nurses from HEE will work with their universities and practice placement providers to look at how to implement some of the best practice guidance in the toolkit over the next 12 to 18 months. John adds that HEE will also be developing new preceptorship guidance and tools, and taking a closer look at the clinical placement learning environment, and what new mentorship models might look like.
‘Some of the smallest, simplest things can make the biggest difference,’ he says. ‘One thing I keep coming back to is the message Chris Beasley [Professor Dame Christine Beasley, chairman of the RePAIR steering group] gave in one of our early meetings: we can all do just a little bit more, and a little bit more makes a big difference.’
Department of Health (2015). Delivering high quality, effective compassionate care: developing the right people with the right skills and the right values.See: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/203332/29257_2900971_Delivering_Accessible.pdf(accessed 2 November 2018).
Health Education England. (2018) RePAIR: reducing pre-registration attrition and improving retention. See: hee.nhs.uk/our-work/reducing-pre-registration-attrition-improving-retention (accessed 2 November 2018).
Health Education England. (2015). Raising the bar: shape of caring: a review of future education and training of registered nurses and care assistants. See:
hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-FINAL.pdf (accessed 2 November 2018).
NMC. (2018) New NMC figures continue to highlight major concern as more EU nurses leave the UK. See: nmc.org.uk/news/press-releases/new-nmc-figures-continue-to-highlight-major-concern-as-more-eu-nurses-leave-the-uk/ (accessed 2 November 2018).
Orton S. (2011) Re-thinking attrition in student nurses. See: wlv.ac.uk/media/wlv/pdf/Rethinking-Attrition-in-student-nurses-Sophie-Orton.pdf (accessed 2 November 2018).
RCM. (2018) Applications to midwifery courses down by over one third - having fallen steadily every year since 2013 says RCM. See: https://www.rcm.org.uk/press-releases/2018/april/applications-to-midwifery-courses-down-by-over-one-third-having-fallen-steadily-every-year-since-2013-says-RCM (accessed 1 November 2018).
Universities and Colleges Admissions Service. (2018) March Deadline Analysis: Overview. See ucas.com/file/159351/download?token=bheqorTl (accessed 9 November 2018).