RePAIRing the damage
A large-scale study into student attrition shares its findings, Juliette Astrup reports.
Every student midwife reading this will likely know of someone who has quit their course, or seriously considered it – they may have even contemplated it themselves. Each time a student leaves it is a highly personal decision – but now a Health Education England (HHE) led study is shedding light on the bigger picture, offering a detailed understanding of student attrition, and what might help students stay.
Since 2015 HEE has been leading a national piece of work looking at attrition and retention in healthcare students and the newly qualified workforce. The RePAIR (Reducing Attrition and Improving Retention) project covered the four fields in nursing – adult, child, learning disabilities and mental health, along with midwifery and therapeutic radiography.
Using a baseline of ‘pure attrition’ – counted as the percentage of students who did not complete within the standard pathway – it found that 33.4% did not complete on time. Over the two years the ‘pure attrition’ rate for midwives was 30.97.
Alongside this raw data, the study included a survey of almost 3500 students, as well as workshops and meetings with stakeholders, and input from 16 case study sites, which explored various initiatives designed to improve student retention.
While it highlighted many positives – for example 97% of survey respondents said they intend to pursue a career in their chosen profession within the next three years, while 96% agreed that they had made the right decision to enrol on the course – the report paints a clear picture of the struggles and challenges students face.
Among their reasons for not completing the course, or for leaving the profession less than two years after qualification, were financial pressures, workload, stress, and personal reasons.
Another key factor was a student’s experiences of clinical placements and mentorship, described as ‘make or break’ by one student midwife involved in the study.
The step-up in workload and responsibility in the second year, and the ‘rollercoaster of confidence’ in the final year transition to practice, were also identified as particularly difficult phases in the student journey.
In all, two in five of the student survey respondents acknowledged they had thought about leaving the course.
‘It really doesn’t surprise me,’ says Deirbhile Murphy, a third-year midwifery student at Queen’s University, Belfast. ‘Many in my class have thought about leaving the course – once a week I’d say – it’s tough.
‘The organisation isn’t great and it’s not family friendly. The girls who do have children are financially really struggling, and even those who don’t are under supported.
‘We’re expected to get on with it. 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.’
Professor John Clark, regional chief nurse and head of allied health, was the lead on the RePAIR project. He believes this, ‘the biggest data set ever collected on the subject’, provides ‘real evidence now to show that students don’t always get the best experience’.
He adds: ‘It’s not always an easy message to hear. 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”.’
He says one of the key things highlighted in the report is the need for universities and practice placement providers to work better together. Being clear about what students can expect – for example in how far they will have to travel to reach a placement, or the amount of time they will have with their mentor – is critical adds John.
Another thing to emerge was the importance of buddy systems, with senior students supporting those coming behind them, says John: ‘Something students really value is having not only someone to mentor them, but someone providing that pastoral support as well.
‘One of the things I would say, particularly to second- and third-year students, is think about what support you can give to your colleagues coming up below you.
‘The university doesn’t need to set up a formal buddy system for you to be able to buddy up with more junior students and support those students coming through, particularly those going into the second year, where we know the level of responsibility, the level of work and student assessment, steps up. Third-year students can really offer some support to second years, and let them know that there is a light at the end of the tunnel.’
The RePair report, published in October, includes 15 recommendations for universities and clinical placement providers, as well as HEE itself, all aimed at improving retention.
These include helping students understand the challenges and demands of their chosen career and study before they begin, improving student support, particularly in year two, creating standardised practice assessment documentation, reviewing preceptorship programmes, and considering greater access to hardship funds, especially for mature students.
Alongside these recommendations a toolkit has been created specifically to help staff in higher education institutions, service provider organisations, and policy makers, reduce attrition with a range of learning materials, videos and examples of best practice.
RCM head of education and learning Carmel Lloyd welcomed the report, particularly its ‘realistic recommendations’ and supporting toolkit.
‘We are never going to have zero attrition,’ she says. ‘But this report focusses on avoidable attrition which is often linked with students who are leaving as a result of things in the system, not things in their personal life. A student leaving because someone was unkind or bullied them, for example, is preventable.’
And for students, if it can help them understand that some of the problems they face are systemic, that is also a welcome benefit, adds Carmel: ‘If something happens to them in clinical practice, rather than thinking: “Is it me?” They can see it’s happening elsewhere, that it isn’t right, and report it.’
If nothing else the report should raise awareness and be a catalyst for new conversations and further work around student and newly qualified staff attrition.
John adds: ‘I know for a lot of people it might make for uncomfortable reading, but I think it’s ok 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.’
Dr Sam Bassett, lead midwife for education at Kings College London, says she has shared the RePAIR report with university staff, students and clinical practice facilitators, as she hopes it will ‘open discussions’ across midwifery education, and ‘get us thinking’.
‘I think students should be aware of this report. It might make for some hard reading, but students are much more savvy than they ever were – I don’t think a lot of this will be news to them,’ she adds.
‘The fact that this is written down, and it is being acknowledged that these are the issues in some places, and that we are trying to work on it and take it forward, should be quite reassuring to them.’
- National bodies should work together to review the current range of definitions of attrition, and model(s) for measuring this metric, to ensure that the output data is meaningful to all parts of the sector, in particular the Health Care Providers (HCPs).
- Higher Education Institutions (HEIs) and HCPs should work in partnership to acquire a better understanding of the cost effectiveness of interventions that are designed to improve retention.
- HEE should seek 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 do understand the career they have chosen to enter and the demands of the course.
- HEIs should review, in partnership with their students, the institution’s approach to buddy schemes for healthcare students.
- 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 and map out detailed placement allocations for all the students, throughout the duration of their course. They should also review processes relating to placement costs and ensure students are reimbursed in an efficient and timely way.
- HEE should work with HCPs and HEIs to ensure that its national strategy, to support students in clinical practice and their supervisors/mentors, is implemented.
- HCPs and HEIs should work together to resolve the dissonance that exists concerning some students’ understanding of their role in the service and the interpretation of students’ supernumerary status, particularly for third-year students.
- HEIs should work together to agree a national standardised approach to assessing and recording students’ clinical competence, including a simple process of recording students’ prior clinical experience.
- 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.
- HCPs should review their preceptorship programmes, ideally in partnership with HEIs, to improve recruitment and retention of their newly qualified staff and ensure the preceptors are appropriately trained.
- Neighbouring HCPs should work together, and with their local education providers, to agree a shared model of recruiting newly qualified practitioners.
- HCPs should gather data about the culture of care in the clinical environments, in which the students are training, to understand the impact of that culture on students’ early career decisions.
- HEE should seek to understand the relevance of the findings from RePAIR to the new models of pre-registration education and training that are being implemented in health and social care.