Nursing education has undoubtedly been affected by the Covid-19 pandemic, with an increase in intercalation and a reduction in attrition important to note and direct future practice across placement and academia. This is a Journal Club article and comes with a handout that you can download and distribute for a journal club discussion.
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Abstract
Attrition and intercalation in adult nursing programmes are notoriously problematic. The pandemic and subsequent actions and guidance from the Nursing and Midwifery Council altered academia and clinical practice affecting student pathways to registration. A clear gap in the literature emerged – to identify the effect of the pandemic on student attrition and intercalation. Data analysis outlines that the pandemic affected attrition and intercalation locally. Between the academic years of 2018-19 and 2019-20, attrition reduced and intercalation increased across our three partner higher education institutions; the University of East Anglia, University of Suffolk and Anglia Ruskin University. It is essential that support and assessment processes are in place to enable progression to registration and that a workforce review is undertaken to establish if there is a resultant deficit in the registered nurse workforce.
Citation: Levitt-Powell A (2023) Student attrition and intercalation during the Covid-19 pandemic. Nursing Times [online]; 119: 11
Author: Alex Levitt-Powell is lead practice education facilitator at West Suffolk NHS Foundation Trust.
Introduction
On 11 March 2020, the World Health Organization (WHO) declared a pandemic with the SARS-CoV-2 virus sweeping the planet at an alarming rate. On 26 March of that year, the UK government enforced a national lockdown and advised everyone to “stay at home” unless working in key roles. The ensuing 24 months irreversibly changed not only the landscape of healthcare delivery in this country but the lives and experiences of student nurses. It cannot be underestimated the toll that the pandemic has had on the nursing profession. Literature examining such effects concludes NHS nurses experienced posttraumatic stress disorder, stress and anxiety during the first wave of the pandemic (Couper et al, 2022). The effect of this increase in demand and effect on wellbeing and mental health in a 2021 survey by the Royal College of Nursing (RCN) concluded that, of those planning to leave the profession, 61.4% stated reasons of too much pressure and 59.9% felt exhausted (RCN, 2021).
In 2021, Health Education England (HEE) published data looking into nursing students’ experiences in the first year since the WHO announcement. The Impact of Covid-19 on Students: Key Findings survey outlined academic concerns and situational stress as the risk factors for increased attrition within nursing courses (HEE, 2021).
Locally, at West Suffolk NHS Foundation Trust (WSFT), student nurses were withdrawn from clinical placements by our partner higher education institutions (HEIs) and re-entered following the publication of the amended NMC (2018a) emergency Standards for Student Supervision and Assessment (SSSA) guidance. The guidance allowed second- and third-year students to take paid placements and join the NHS workforce in its time of need. The effects of these decisions are yet to be fully established; however, there is scope to examine data trends post-Covid-19 restrictions to identify changes in attrition and intercalation for our educational partners across this period.
There is a plethora of texts that study the impact of Covid-19 on stress and resilience in both pre-registration and registered nursing. Examples such as Manzanares (2021) measuring resilience grown through the pandemic do not, however, measure the effects on student pathways within their courses. Similarly, many studies outline the complexity of decisionmaking that students have been forced to balance, including opt-in placements, the sense of failure if opting out, and financial costs including extended learning (Swift et al, 2020).
Before the pandemic, HEE commissioned the empirical report Reducing Preregistration Attrition and Improving Retention (RePAIR) where the findings were clear – that the problem of attrition from nursing programmes remained (HEE 2018a). While healthcare delivery is in recovery from the pandemic, it is important to establish the effects this has had on the NHS, HEIs, and the students studying nursing programmes locally. The first Impact of Covid-19 on Students survey (HEE, 2021) reviewed student experience during the pandemic and focused attention on supporting students in programmes. Survey II has since been published and identifies a stark reduction in placement quality and an increase in students considering leaving their courses (Chartered Society of Physiotherapy, 2022). Therefore, the evident gap is to study what is happening locally and examine themes in the data to make recommendations that are implemented to support students and plan for the future.
Study aims and analysis method
This study aims to determine whether the pandemic has affected adult nursing pathway intercalation and attrition at our partner HEIs and to make recommendations based on the findings.
A quantitative design was selected to analyse pre- and post-Covid-19 restrictions data. As many previous studies have discussed qualitative causes of intercalation and attrition, it was important to study the numerical data to establish the effect of the pandemic. It was important to focus on quantitative data alone as there is not a clear cause and effect outcome expected, although the trends in the data would show themes that could be associated. Comparative analysis was used to establish themes in the collection to allow for local recommendations around pre-registration practices.
Data was collected via freedom of information requests to each partner university detailing attrition and intercalation from cohort September 2017 to September 2021. There were no demographics specified within the data request and published data were pseudonymised before receipt. Data was included from adult nursing (traditional three-year BSc) cohorts: September 2017 to January 2021 at our partner HEIs.
Results
The causes of intercalation and attrition are widely discussed (Canzan et al, 2022; Hoeve et al, 2017). Both qualitative and quantitative studies have already been explored and reasons for students not completing on time are varied (HEE, 2018b). The data analysed locally from Anglia Ruskin University, University of East Anglia and University of Suffolk shows that this conundrum has not gone away.
Data has been analysed to ascertain how each university differs from the other. The data will examine the academic year data from all three years of the pre-registration programme rather than cohorts individually, therefore, measuring the impact of the virus on students collectively. The existing attrition and intercalation qualitative causes have not been included in the study, however, are discussed in the findings.
Data analysis illustrates how each university differs from the other – this is not to compare performance, but instead to ascertain partner trends combined and to establish if there are patterns across our partner HEIs.
Intercalation data from our partners drawn from individual analysis shows that there were increases across all three partner HEIs between the academic years of 2018-19 and 2019-20. Fig 1 shows a graph of this data.
Attrition data from our partners drawn from the individual analysis shows that there were decreases across all three partner HEIs between the academic years of 2018-19 and 2019-20. Fig 2 shows a graph of this data.
<img loading="lazy" decoding="async" class="alignnone wp-image-306455 size-full" src="https://s3-eu-west-1.amazonaws.com/emap-moon-prod/wp-content/uploads/sites/3/2023/10/Fig-2.-Attrition-rates-across-all-three-HEI-partners-between-the-academic-years-of-2018-19-and-2019-20.png" alt="" width="1388" height="752"/>
Discussion
Data from our partner HEIs has been analysed for themes in intercalation and attrition to be able to evidence the effect of SARS-CoV-2 in adult nursing programmes. Data clearly outlines an increase in intercalation between the academic years of 2018-19 and 2019-20 (September to August) and a decrease in attrition over the same period. Each university has differing rates of attrition and intercalation within this data sample, however, the trends for each are representative of a change in practice. It would be natural to suspect that there is a cause and effect relationship between these data sets, however, additional statistical evidence has not been sought within this study to prove this and, therefore, remains within the scope for further research into the field. However, there is potential that there may be a theoretical relationship between the two.
The effect of the increase in intercalation is not yet fully understood, however, it will impact the number of nurses entering the profession on time, therefore, affecting trusts’ workforce plans locally. If findings are considered on a national scale, there may be a reason to believe that the UK government’s 50,000 more nurses by 2024 target (Department of Health and Social Care (DHSC), 2022) may be short of projections and attributed to the effects of the pandemic. An alternative factor that would affect the potential to achieve the 50,000 target is the reduction in applicants drawn to the profession in the wake of the pandemic. Universities and Colleges Admissions Service (UCAS) data illustrates a poor year for applications to adult nursing courses across the country, falling 8% on 2021 figures (UCAS, 2022). Holmes and Maguire (2022) describe the 50,000 target as “hitting the numbers but missing the point,” with increasing healthcare demand and greater vacancy rates, both HEIs and healthcare workforce systems are struggling to keep up with this supply demand. Retention of nurses throughout the pandemic was reported to be relatively stable. However, the concern is growing that, post-Covid-19 restrictions there is potential for the rates to deteriorate, due to the pressures on staff; this is reported within quantitative national data (NHS Digital, 2022). Regionally, the East of England has outperformed the national average for full-time equivalent (FTE) vacancies. During the period between June 2018 and June 2022, the East of England reported a 10.3% vacancy rate against a national average of 10.8%. More specifically, the East had seen a rate of 9.0% from June 2021 to June 2022 compared to 11.8% nationally (NHS Digital, 2022). Therefore, trusts should review workforce plans to compensate for any shortfall in domestic registrants, with overseas recruitment a possible, short-term solution. It is also essential to retain nurses already employed at the trust to ensure that vacancy rates remain controllable.
Any reduction in attrition can be seen as a positive movement. All three partner HEIs report reduced attrition across the timeframe. This may be due to increased flexibility and understanding of the additional pandemic stress factors affecting study, hence increased intercalation.
Further research is needed to establish if the students who remained on programmes (intercalated) completed the course to registration. While there will be strong-performing students within these groups, where intercalation was enforced due to personal circumstances and/or health risks, there may be students who did not perform in placement and requested intercalation as an alternative to attrition. It is likely there will be students who have intercalated due to poor performance. Examination of the attrition data in unison from intercalation is, therefore, essential.
It is assumed and discussed previously that, as attrition reduces, intercalation increases. These two outcomes, however, may have no relationship. Has attrition reduced due to a different cause, for example, failure to fail? Failure to fail is defined as “students passing clinical courses when they do not meet the profession’s standards of proficiency” (Hughes et al, 2021a).
Failure to fail remains an issue, especially in the wake of the pandemic (Adkins and Aucoin, 2022). Causes range from fear of the receiver’s anticipated emotional reaction, fear of distressing the receiver and fear of being evaluated negatively (Dibble, 2014). The risks of failure to fail are well documented (Hughes et al, 2021b). Allowing a student who does not meet practice standards to pass is a significant concern and is seen as a breach of ethical and professional credibility, as well as a patient safety risk (NMC, 2018b). Driving SSSA in practice is, therefore, essential as we recover from the pandemic to ensure that students feel supported, equipped, and ready to join the workforce upon completion of their nursing programmes (NMC, 2018a).
Local partnerships must remain well established and supportive to students studying adult nursing programmes. It is essential that the changing needs of students are understood and that academic and practice support must be flexible to these changing needs. Circumstances may require students to remain in a recovery period to ensure that 2,300 hours of practice learning is achieved. To ensure support and competence, it is the author’s view that robust assessment is essential to ensure that workforce and registration needs are met.
The findings within this study give insight into partner HEI intercalation and attrition, and the themes evidence pre- and post-Covid-19 restrictions on student pathways across the timeframe. The study findings are clear. The data accessed enabled a robust descriptive analysis of the rates of attrition and intercalation, but does not offer absolute clarity on the causes of the decrease and increase respectively. Reasons for intercalation are multifaceted and the data accessed does not include depth and clarity to establish this cause. This could be sought by investigating the data further and studying qualitative causes for intercalation and attrition. Findings cannot be generalised to other HEIs and practice placements, however, recommendations and awareness of the issues can be adopted by academia and practice to support students in nursing programmes. The strength in data trend is helpful to guide future practice, although further research is essential to understand if students continue on the programme and complete it. It would be useful to understand if the pandemic has invariably changed practice for the foreseeable future, or if attrition and intercalation return to pre-pandemic trends.
Conclusion and recommendations
The SARS-CoV-2 pandemic has undoubtedly affected adult nursing education pathways with a clear increase in intercalation and reduction in attrition. This change in norm is important to highlight and direct future practice across placements and academia. Processes must be in place to ensure that students who remain on the programme are supported to bridge any gaps in clinical practice. This includes practice hours, competence, and robust assessment to ensure that students complete their programmes ready to join the workforce fit to care for our patients in an era after Covid-19 restrictions. Clinical educators must ensure that they work closely with universities to identify struggling students and that adequate signposting is in place to support progression.
The DHSC target of 50,000 additional FTE nurses by 2024 is a strongly reviewed and studied target. It is essential that further research establishes a vacancy factor locally for all streams of nurse recruitment, including overseas nurses. This would enable an analysis of workforce plans to ensure a workforce fit to care for the local population in the future. This would be sought by establishing if a short-term drop in ontime registrants had a cause and effect relationship on vacancy factor locally.
There is no doubt that the data depicts clear trends across all three HEIs. However, further qualitative research is essential to strengthen the hypothesis that the pandemic affected attrition and intercalation. This research would identify if the causes were Covid-19 related and give further explanation to these themes. There will also be the opportunity to examine other fields of nursing programmes to establish an impact on the profession in its entirety.
The data within this study must be used as a starting block to discover the true extent of the impact of the pandemic on students and student pathways. The recommendations for further research will give greater clarity on the effect of the pandemic and workforce and service provision moving forward. Findings from this study cannot be generalised due to scope, though may be adopted and steps must be taken to implement student support initiatives, ensuring nursing programmes continue to deliver and meet health service needs.
Key points
Students were withdrawn from clinical practice during the pandemic following guidance from the Nursing and Midwifery Council and re-entered under emergency standards
Student attrition during the pandemic timeframe reduced at partner higher education institutions
Intercalation over the pandemic timeframe increased at partner higher education institutions
A supportive culture is required to support students to registration, ensurin
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