As the UK moves towards ‘Brexit day’ on 29 March 2019, when we are scheduled to leave the EU, with or without a deal, there are serious implications for the nursing and wider healthcare workforce to consider, according to a report by the National Institute of Economic and Social Research (NIESR) published at the end of 2018 (NIESR, 2018).
The report, commissioned by a large group of health and social care organisations, known as the Cavendish Coalition, estimates that there will be a nurse shortage of 51 000 by 2021, the end of the Brexit transition period.
Health and social care in the UK is heavily dependent on nurses from the European Economic Area (EEA) and elsewhere. Since the referendum, EEA recruits to the UK fell by 18%, and 15% left the UK (NIESR, 2018). The report states that, whereas there were 42 000 registered nurses (RNs) working in social care in 2017, almost one third had left in the 12 months to November 2018.
Clearly these figures raise significant implications for care quality but, given the model for pre-registration nurse education in the UK, which is dependent on work-based RN mentors and assessors, in the longer term high numbers of RN vacancies may also impact on nurse education.
Even before the EU referendum and its result, nurse and midwifery vacancies were a matter for concern. There is a considerable regional variation as well as within specific specialties. For example, London has the highest nurse vacancy rates in England (14%) according to Jones-Berry (2018a), with factors such as the high cost of living playing a key role. Mental health and learning disabilities RN vacancy rates are particularly high, as well as those within community nursing (NHS Providers, 2017).
The number of training places offered and taken up by students, known as the fill rate, is a key factor in managing workforce projections. Before the withdrawal of the nurse student bursary and introduction of course fees in 2017, the NHS commissioned nurse and midwifery pre-registration student places regionally, in response to projected needs. It was argued that deregulation would open up more student places by encouraging more education providers into the market, but there was actually a small decline in student acceptances (UCAS, 2017). According to the Royal College of Nursing (RCN) (2018a) numbers applying for pre-registration programmes in September 2018 declined a further 12% compared with 2017, particularly among mature students.
Pre-registration nursing courses involve 50% of the programme hours in university-based education and 50% in clinical practice. Students are supervised and assessed by RN mentors who undertake this activity following preparation, but alongside their normal clinical workload.
With an increasing shortage of RNs, availability of mentors may become problematic. It is likely that, despite the best of intentions, adequately supervising and assessing nurse students, as well as nurse associates and healthcare assistants, will become increasingly challenging for RNs. This could potentially lead to stress and burnout. This may then affect nurse retention; a number of studies highlight factors impacting on nurse retention, including quality of the practice environment, nurse leadership and their impact on burnout (RN4CAST, 2012; Roche et al, 2015). Add to this an unprecedented demand for health care, mainly because people are living longer with multiple chronic health conditions (RCN, 2018b). It all means the demands on RNs and RN nurse mentors are very high.
As a nurse lecturer I am fully aware of the importance nurse students give to the clinical placement element of their programme. However Jones-Berry (2018b) reported that 25% of student nurses fail to complete their pre-registration education programme. Clearly, academic and financial pressures play a part but so do clinical placement experiences around supervision, feeling prepared for levels of responsibility, and stress concerning increased workload. Halter et al (2017) found that supervisor support was the most reported determinant for retention of RNs; it seems likely that this factor is as important in the supervision of nurse students.
Education and health service providers need to work together to ensure adequate support for students in practice. With the Brexit process rumbling on, reduced nurse student applications, an ageing RN population and increasing patient care needs, the ongoing nurse shortage does not look like it is going away. This issue needs careful monitoring.