On June 30 2023, the NHS released a Long Term Workforce Plan, outlining its vision for the future trajectory of the NHS. One of the objectives outlined in the plan is the enhancement of the NHS workforce, involving the reformation of current training of healthcare workers including student nurses.
Within the workforce plan the NHS communicated that they aim to train “5,000 NAs [Nursing Associates] in both 2023/24 and 2024/25, increasing to 7,000 a year by 2028/29”.
However, the escalating attrition rates among nursing students across the UK have resulted in concerns regarding the feasibility of achieving this target – especially within the specified timeframes.
One individual expressing significant concern is Pat Cullen, who serves as the General Secretary and Chief Executive of the Royal College of Nursing. On February 14, 2024, Cullen issued a letter to the Secretary of State, which drew attention to the fact: "New data from UCAS reveals a 10 percent decline in nursing degree applicants to universities in England compared to 2023. This represents a 26 percent decrease in just two years, marking the lowest number of applicants since 2019”.
Cullen also wrote: “Failure to address these critical issues will make the ambitions set out in the NHS Long Term Workforce Plan unattainable”. The full letter can be accessed on the Royal College of Nursing website.
However, nursing degrees have not only seen a reduction in applicants but also in the number of students completing the full course of their degree.
Data collected from 125 individuals, found that, after one year of studying BSc (Hons) Adult Nursing at the University of York, eighty-three percent of students continued with their studies (data entrants in 2020-21). However, seven percent of students left without obtaining their qualifications and eight percent took a break from their studies after one year on the course.
Nouse asked Professor David Barrett, Deputy Head of the Department of Health Sciences, what he thought of the NHS’ Long-term workforce plan. “The principles behind it are absolutely sound. From an apprenticeship perspective I also really support it” said Professor Barrett. He also highlighted a key challenge in achieving this plan, which is the fact that nursing is a difficult environment making it harder to recruit and retain staff by stating: “If people don’t feel they have the support they need, then like any job, they will leave. So, retaining staff in certain areas is difficult as well”.
In light of the evident decline in the completion rates of undergraduate nursing degrees, Nouse engaged with several students at the University of York to obtain a more comprehensive understanding of the current state of student nursing.
One of the students Nouse interviewed is in their third and final year, studying BSc Adult Nursing. Due to an incident which occurred during one of their placements, the individual has requested anonymity, and will be referred to as ‘the student.’
Firstly, Nouse asked the student: ‘Which aspects of studying nursing at the University of York have most positively influenced your overall experience?’ The student began by explaining that, as an individual with dyslexia, they appreciate the way York separates term time between academic teaching and placement. They stated that this was a key factor which had influenced their decision to study at York, as opposed to other universities.
Despite the initial assurance of support for their dyslexia, the student expressed disappointment regarding the lack of support they have recieved from the University. “The support has been really limited, and I have had to go out and find a lot of support on my own” the student explained.
In response to this, Professor Barrett expressed that he was “really sorry” to hear, that in the case of this particular student, they felt they had to “fend for themselves” and he encouraged the student to reach out to him directly, should they feel comfortable doing so. Professor Barrett further commented that he recommends that prospective students, and those already studying at the University, engage with the support available. “Once we know that somebody has got those additional needs, we can make those adjustments [and] we can provide whatever support is required,” he remarked. “I think [that], with the central University’s support systems coupled with the additional support offered by the department, I hope, for our students, does provide the support they need” Professor Barrett added.
The student further opened up about their challenges, disclosing the fact they had considered dropping out of their degree on multiple occasions. When Nouse asked about the specific triggers behind this contemplation, the student indicated a pivotal factor – an especially challenging nursing placement.
Although the student had reached out to the University with a request for reallocation, they informed Nouse that they were told to continue with their current placement. As a consequence, the student had to persist with this challenging placement, despite expressing the fact it was having a detrimental effect on their mental wellbeing.
The University of York’s policy on re-locating nursing students to alternative placements are managed through the placement change request process. Professor Barrett explained that allocations are made a few weeks before students officially start their placements; providing them with enough time to identify any particular issues. He explained this includes issues such as accessibility, financial concerns or personal matters. In this instance, the University explained to the student, that they were unable to relocate them to another placement due to the limited time and availability.
The student also highlighted another challenge, noting that they were placed in an elderly ward where they encountered eight deaths during a twelve-week placement. “For all eight of those deaths, I had to do the last rights including washing and wrapping the body — which is emotional in itself,” the student said.
They continued to state this was a highly emotional experience, which was exacerbated by their perception of the “de-sensitisation” of qualified nurses on the ward. Instead of being given sufficient time for reflection and to discuss their feelings regarding these deaths, the student emphasised there was a complete absence of follow-up on the ward. “Nobody asked me ‘how do you feel about this’ or ‘are you okay?’ It was like let's go onto the next thing and just ring the porters to come and pick up the body”.
York and Scarborough Teaching Hospitals NHS Foundation Trust have stated: "The comments do not represent our students as a whole and we regularly receive positive feedback from our student nurses We have an excellent partnership with all our higher education institutes. This includes regular meetings to discuss student issues and review placements which are regularly evaluated, and any feedback and learning acted upon.
"The health and well-being of all our staff, including students is important to us. When students are allocated to a placement they are all given a named practice assessor and a practice supervisor to ensure they feel supported. Students can also speak to practice education facilitators who are assigned to all placement areas, where they are encouraged to raise any issues they may have in a confidential and safe space. In addition, most wards also have a designated professional nurse advocate who is there to support all nursing staff, including students".
The third year continued to comment that the only time student nurses can stop and fully process their day of placement, (each twelve hours long) is once they arrive home. However, the student noted that, at this point, exhaustion from the day has set in.
This prompted Nouse to ask the question: ‘What is the University doing to prepare student nurses for dealing with patient deaths and do you feel this support is enough?’
The student replied: “In first year, you have a whole term of theory before you go on placement and in that term of theory, there needs to be more discussions about the fact that, as a student nurse, you are going to see people die. You subconsciously know that [you will witness deaths], but you don’t realise how impactful it is until it happens”.
This led Nouse to inquire about the department's efforts in preparing student nurses to handle patient deaths. Professor Barrett, in response, emphasised that, as a department, they actively incorporate strategies to address challenges encountered by students during their clinical placements. This encompasses the practical elements of performing the last offices and dealing with the emotional aspects.
Another issue which contributed to the students’ negative experience of placement stemmed from their fear of saying “the wrong thing” while consoling grieving relatives. The student emphasised the variability in how each relative responds to a patient’s death, adding: “Each relative reacts differently and when a patient does die, you then have to look after the relatives of that patient”. They explained student nurses must adapt to the unique demands of each situation, which has increased the emotional burden of their responsibilities.
When Nouse asked what could be done to better prepare students for these circumstances, the student voiced the need for greater conversations about the emotional impacts of patient deaths. They also commented that student nurses should be given greater guidance on how to console relatives who have suffered a loss.
Acknowledging the University’s provision of a space for students to discuss patient deaths, referred to as the 'Death and Dying Cafe,' the student stated the cafe was only available for second-year students. They stated that this was “pointless” as they think the Cafe needs to be accessible to students in first-year.
Professor Barrett clarified that the decision to postpone the 'Death and Dying Cafe' until second year is to enable students to not just discuss potential encounters but also to allow time for reflecting on their past experiences with patient deaths. He explained: "It is absolutely possible that students may see deaths in [first year] during their first placements, so there is a temptation to think we [should] talk about it loads in the first term. But we also don’t want to scare students off or give people complex information that they are not quite ready to deal with".
Nevertheless, he emphasised that introducing more sessions for students to discuss patient deaths earlier on in the course, is something he would consider implementing in the future and discuss with the department moving forward.
Now that they are in the final year of their nursing degree, the student attends ‘End of Life and Communication’ seminars, which they remarked are “great”. However, their primary concern is: “What we learn at university doesn’t reflect in placement, as you don’t have those moments to debrief on placement”.
Loneliness is another issue which student nurses have to contend with, often due to the structure of undergraduate nursing degrees. The student explained that at the University of York, nursing students have shorter holidays than students on different degree courses, such as Arts and Humanities.
Nouse asked the final-year student if they felt the lack of breaks between teaching and placement during their degree thus far had impacted them – the student confirmed they had indeed made an impact.
During their interview with Nouse (which took place in mid-January 2024), the student explained that their housemate, a third-year English Literature student, won’t be attending teaching until mid-February of this semester (2023/2024). However, as a nursing undergraduate, the student has already completed a whole month of teaching. “We are always the last ones by ourselves in the summer… Yes, we have each other, but you feel alone on campus. All the cafes on campus shut down and you think, I don’t even have social spaces [to visit on campus] at the moment, because to them [the University], they are finished for the semester. It feels lonely sometimes, especially if you don’t live with other nurses” the student said.
They continued to express: “We only get two weeks off at Easter and three weeks off at Christmas and then six weeks over Summer. It never feels like enough time… you don't have time to check in with yourself. Instead, we [student nurses] just have mental breakdowns. It is the only time where we will cry. It’s like you just don't get a break for the whole three years. When you have reduced holidays, reduced social chances, no wonder people drop out”.
When Nouse asked if the student felt like their inability to join societies and attend other university-based events had negatively impacted their university experience, they replied: “Massively. Massively. I was part of a sports society but I had to stop because it was too much. I was getting stressed”.
The student also told Nouse that they work part-time which has further reduced their time and energy to join societies. “We [nursing students] do not have the luxury of time like other students to fit into societies and sports groups. A lot of nurses then miss out on the university experience,” they remarked.
NurSoc is a student-led society which predominantly targets student nurses and trainee nursing associates at the University of York. When Nouse asked NurSoc if they could comment on the challenges faced by student nurses, a member of the society told Nouse: “There are a number of challenges faced by student nurses today nationwide, and every student will have their own perspective on this".
The NurSoc member further explained: “Our society aims to provide space for student nurses to relax with other student nurses. We aim to provide an informal space with people who understand the challenges of the course”.
Although the student stated they were familiar with NurSoc, they explained the society was not really of interest to them, given the fact they already lack opportunities to engage with non-nursing students and the wider student community.
Nouse then asked how confident the student feels about entering a career in nursing, post-graduation to which they replied: “I think the NHS is in a state of crisis”. However, they said the only option is for healthcare professionals to carry on. “We cannot stop nursing. We do it for the patients at the end of the day. But I think there is going to be a lot of turmoil in the next coming years depending on the government of the UK”.
The financial burden which derives from the cost of commuting to and from nursing placements also proves to be a challenge for student nurses.
Nouse spoke to Zaria Ugonna, a second-year undergraduate at the University of York, to develop a greater understanding of her experience as an international student nurse.
Firstly Nouse asked whether Zaria felt like her experience as an international student was different to domestic students. She replied: “As an international student, I would say the biggest difference is that we do not get any financial compensation for travelling to placement or buying accommodation to be closer to placement. ”
The second-year nursing student further detailed her experience, highlighting that she was assigned a placement that posed challenges in terms of accessibility through public transport. Upon raising the issue with the University, Zaria was presented with the solution of renting accommodation in closer proximity to the hospital –– where she was due to complete her placement. However, she expressed, this was outside her financial capabilities. Zaria stated: “When I explained to them [the University] that I was [an] international [student] and that this accommodation would have to come out of my pocket, they were not understanding”.
Zaria remarked that the University had left her to her own devices, instructing her to independently navigate the cost of commuting to and from her placement. “I ended up needing to travel four hours a day to get to placement just to make it on time for shifts. I wish that the department took this into consideration and would send students who cannot drive to locations that are a bit easier to get to” she stated.
Due to national policy, whilst most domestic students are entitled to receive a £5000 non-repayable support fund, international students are not.
Nouse asked: ‘Given the inability of international students to access the same support as domestic students, how is the department supporting international students?’ to which Profesor Barrett replied: “There is no doubt that this is an additional burden on them [international students]. It is something we try and take care to acknowledge when we are allocating placements. It is something that we, and other universities have highlighted on a national level”.
He further acknowledged the fact that the lack of financial support for international students is unfair: "These are still incredibly motivated students who will be a really important part of the future of the NHS workforce. We [the department] feel that they should therefore get the same support”.
Also on the subject of finance, Nouse asked if and how the cost-of-living crisis had affected Zaria’s studies and her experience of placement. Zaria replied: “I have to budget tremendously to be able to afford to get transport to placement which can add up to considerable amounts…I have had to skimp on food shops near the end of the month to be able to afford to get to placement”.
When Nouse asked about additional challenges she had encountered as a student nurse, so far, Zaria mentioned that the difficulties during her placement primarily stemmed from the broader problem of understaffing within the NHS.
As stated on the Royal College of Nursing website, student nurses “should not be placed in a situation where adequate levels of support cannot be guaranteed.” Nursing students should also not be placed “to make up the numbers”.
However, Zaria expressed she felt she had been brought into work, to compensate for NHS staff shortages “on many occasions”. She explained this has been to the detriment of her ability to immerse herself in practical learning during her placement.
Zaria further stated that during her first year as an undergraduate nursing student, she was inappropriately assigned the “sole responsibility” of watching over an elderly patient to ensure they did not fall or acquire any injuries. She expressed: “It was not appropriate for York Hospital to assign me to do this as I did not have the experience needed to provide proper support effectively. The patient was not in proper care due to my lack of experience.”
York and Scarborough Teaching Hospitals NHS Foundation Trust responded to this by stating: "End-of-life care forms part of the nursing programme; however, at times, students will experience the reality of the role, although should never be expected to do anything outside of their scope of practice".
When Nouse questioned how Zaria has navigated these challenges, including balancing her placement with taught theory, she explained that her friends have been crucial in reducing her stress levels and allowing her to feel less lonely. “I have effectively managed to cope with the pressure of this role because of the friends I have made on placement… It is really helpful to be able to meet up and talk to them about the things I've experienced and know that they are going through similar things,” Zaria said.
Nouse also spoke to Olivia Bull, who graduated from the University of York in 2023, after completing an adult nursing degree in 2022. When Nouse asked, Olivia if she felt her degree had adequately prepared her to enter a career in nursing full-time, she replied: “I think that when I qualified I was shocked at having the responsibility of a nurse. When you are a student you are aware that you can make mistakes as you are there shadowing [qualified nurses and healthcare professionals] but as a qualified nurse you feel the pressure to be perfect”.
Nouse then inquired if Olivia had a positive experience as a student nurse. In response, she stated she enjoyed studying at York and found the University to be very supportive: “I was offered occupational health support for my mental health and also encouraged to take time off when I was struggling. I had a personal supervisor called Alison who was very supportive and was available on short notice when I needed help”.
Finally, Nouse interviewed second-year nursing student Josie Conbib. When Nouse asked if Jose felt the University of York sufficiently supports student nurses she replied: “Honestly I feel like they do as much as they can do but it’s a structural problem and the solutions we need are beyond the capabilities of the University”.
Josie further commented: “Financial pressures are at large seeing as we do 2500 hours of unpaid work, over the three years.” She stated this reduces the time student nurses have to earn money through paid work during their degree.
Furthermore, Josie stated she thinks the current state of student nursing is a national problem which needs to be tackled by the government. She proposed student nurses would be better off if they earned an apprentice wage, rather than having to complete their training and degrees, unpaid.
Despite the existence of petitions advocating for student nurses to receive a minimum wage payment for their placement work, the government's stance remains unchanged, maintaining the policy of not providing payment to students throughout their undergraduate nursing degrees and mandatory placements.
Nevertheless, nursing unions including the Royal College of Nursing, are continuing to plead for more support for student nurses and nursing apprentices, with the belief that such measures will improve the future of nursing.
In the meantime, students at the University of York are encouraged to reach out to the department if they are struggling, this includes during their time on placement. Professor Barrett highlighted: “If anybody is finding placement difficult or worried about something they have seen, just talk things through with us and wherever we can help we will help”.
For more information on how and where to access support, students can visit the University of York’s dedicated support page. Support is signposted on the Royal College of Nursing website.
