An ambitious plan to attract more graduates from other disciplines into pre-registration nursing programmes was launched in July by Health Education England (HEE) (2021).
Background
Ever since the passing of the Nurses Registration Act in December 1919, leading to state registration for appropriately trained nurses, there has been a shortfall in the number of nurses needed to ensure optimum care delivery (Glasper and Carpenter, 2019). The shortfalls were initially attributed to how few of the nursing workforce were allowed to join the register after the Act introduced stringent entry requirements, resulting in the exclusion of many health workers who had previously described themselves as nurses. It was only after the introduction of a national nursing curriculum in the wake of the foundation of the General Nursing Council, the forerunner of the Nursing and Midwifery Council (NMC), that nurse education was standardised irrespective of where a nurse was trained.
Since then, the problem of attracting sufficient numbers of registered nurses has preoccupied the nursing profession. The introduction of enrolled nurses in the mid-20th century and nursing associates in the 21st were both attempts to boost the supply of better educated nursing support workers. However, the provision of better educational opportunities for healthcare assistants to enable them to join the nursing profession addressed only one side of the coin; it failed to boost the number of registered nurses necessary for the basic functioning of the NHS.
Successive governments have for years relied on overseas recruitment to alleviate nurse shortages and for a while this seemed to be successful, especially in terms of recruiting nurses from European Union (EU) countries. However, given changing demographics, especially increasing longevity and, consequently, more elderly people with long-term conditions, even this strategy has proved inadequate, not helped by Brexit and changes to how nurses from non-EU countries can join the UK register.
The demise of overseas nursing programmes and their replacement with the more complex Test of Competence, as well as the need for applicants to show proficiency in English, have proved problematic for many. The International English Language Testing System has four elements: speaking, listening, reading and writing. To work in the NHS, candidates need to score at least 7 out of 9 in each section, although anecdotally native English speakers sometimes fail to score 7 in each section.
The government's NHS Long Term Plan (NHS England/NHS Improvement, 2019), which sets out a 10-year vision for health care in England, is still in danger of being derailed by the shortages. Maintaining patient safety through optimum levels of trained nurses was recognised in National Institute for Health and Care Excellence (2014) safe staffing guidelines for adult hospital wards and remain pertinent today.
Over the years, much research has focused on how nurse staffing levels affect patient safety. For example, Rafferty et al (2007) showed that hospitals with the highest patient-to-nurse ratios had a 26% higher mortality. Similarly, Griffiths et al (2018) showed that low levels of registered nurses are associated with reports of missed nursing care. An investigation by the Nursing Standard and independent charity the Health Foundation revealed that up to 25% of students are failing to complete their nursing degrees (Jones-Berry, 2020).
As with other higher education degree courses, there is always some attrition, but the situation within nursing is exacerbated by natural attrition as nurses retire or leave the profession for other reasons (HEE, 2021).
Much of the problem is financially related and follows the abolition of student nurse bursaries, although Prime Minister Boris Johnson has said the government will restore the bursary for nursing students in the guise of a maintenance grant of £5000-£8000. Furthermore, the second decade of the millennium saw cuts to student nurse commissions in many parts of the country, sometimes by up to 20%, which is now perceived to have been a catastrophic decision by the HEE. In 2019, the shortage of trained nurses soared to an all-time high of 41 000 vacancies, with nearly 1 in 8 posts left unfilled. As of June 2021, data from NHS England and NHS Improvement show a vacancy rate for registered nurses of 10.3%, equivalent 38 952 nurses (NHS Digital, 2021).
This latest HEE (2021) report, Nursing: Postgraduate Preregistration Expansion, suggests that if action is not taken to attract more people into the profession nursing vacancies could rise to 100 000 within 10 years. Although the country has in the past relied on the recruitment of nurses from overseas, it is now crucial to grow the domestic supply of registrants from UK educational institutions. There have been recent efforts to increase the supply of nurses from universities, but it takes 3 years to educate a nurse and it is for this reason that HEE is supportive of the 2-year postgraduate route.
Why the postgraduate route?
HEE commissioned the latest report to identify graduates who could be encouraged into nursing via the postgraduate diploma/master's degree route. The report recognises that there will be hurdles to overcome for some of those switching careers. This may involve loss of income, as well as acquiring new debt from additional study, highlighting the importance of providing these potential postgraduate students with financial assistance.
In terms of the options to increase the number of registrants, HEE considers the postgraduate route as a particularly attractive option, principally because the programmes take only 2 years, enabling a fast route to NMC registration, which is at least a year shorter than existing nursing apprenticeships and undergraduate programmes. In addition, people with other subject degrees and work experience in other sectors bring proven academic credentials and general experience, resilience and skills—attributes that make them well suited to nursing.
Against this backdrop the HEE report explores a number of research parameters:
- Factors that motivate people to apply for postgraduate training in nursing and the content that works well to enhance this
- Barriers to applying for postgraduate nurse training, including the myths around this study route, and how to counter these
- The decision-making journey, understanding potential touch points in terms of information or messaging needs (what kind of content works well in respect of these), and times and places to reach the target audience
- Understanding what can enhance perceptions of nursing careers and the postgraduate route to become a more attractive option.
All graduates from university degree courses acquire a set of skills that are valued in all workplace environments. The University of Edinburgh (2021) is not alone among universities in considering that its graduates, irrespective of which degree they have completed, have acquired specific attributes by the point of graduation and are:
- Creative problem-solvers and researchers
- Critical and reflective thinkers
- Effective and influential contributors
- Skilled communicators.
These attributes apply equally to nursing, so potential entrants to a postgraduate nursing course will already have many of the academic skills that underpin the art and science of nursing education, such as being able to source and critically appraise scholarly literature. It should be stressed that, unlike nursing, many undergraduate university courses are not vocational and therefore do not automatically lead to a job.
A significant number of graduates do not therefore automatically gain employment in an area of their choice and are potentially suitable for entry to nursing via the postgraduate route. Recent graduates aged under 30 years, and especially those with social science or psychology degrees, are perceived as potential recruits.
HEE is, however, aware of the sometimes negative factors associated with nursing, such as shift patterns. Its latest report shows that postgraduates may be more interested in community or primary care-based nursing roles following registration, especially of they have young children and the hospital environment, with varied shift patterns, may be less attractive as a job option for some.
The report also shows that knowledge around training routes is generally poor among graduates who do not already work in health and social care, with little understanding of the different options, education level or type of qualification nursing education leads to. As a consequence, the HEE recommends that universities launch advertising to draw attention to nursing as an appropriate profession for graduates who are considering a career switch—one that makes clear the route of postgraduate nurse training. In context, the salary scales linked to nursing posts, career progression and a perceived low chance of redundancy could be especially attractive for graduates whose current employment has been negatively affected by the pandemic.
Despite unambiguous advertising highlighting the positive aspects of postgraduate nurse training, the HEE report points to practical barriers that may potentially thwart a graduate's decision to opt for the postgraduate route into nursing. These include financial commitments, concerns about salary level and shift work. However, the principal barrier is the financial commitment involved in switching careers. HEE suggests that marketing targeted at graduates should make clear both the costs and the financial support that is available.
Although a postgraduate course is a route into nursing, the HEE report acknowledges that the current nursing apprenticeships might be more suitable for younger graduate applicants or those without existing family responsibilities, where tuition fees are fully covered and where the student is treated as an employee and receives pay for the duration of the course.
There is no doubt that recruitment to the nursing profession from the existing graduate workforce is feasible. Students entering these nursing courses now benefit from the new annual maintenance grants of £5000, with some eligible for additional funding for child care or for studying in geographical areas with particular workforce challenges. It is to be hoped that the new drive to recruit graduates into shorter pre-registration courses is successful.
KEY POINTS
- Health Education England has launched a plan to attract more graduates from other academic disciplines into pre-registration nursing programmes
- Since the Nurses Registration Act was passed in December 1919, which led to state registration for nurses, there has been a shortfall in the number of nurses needed to deliver optimum care
- Successive governments have for many years relied on overseas recruitment to alleviate nurse shortages, but this has changed since Brexit
- Postgraduate nursing programmes are particularly attractive for resolving nurse shortages, principally because the programmes take 2 years, offering a faster route to NMC registration