Monday, 18 May 2015

The case against bursaries and fee payments for nursing students

Roger Watson, Professor of Nursing, University of Hull
Editor-in-Chief, Journal of Advanced Nursing

In the UK nursing students do not pay fees to attend university and they are provided with means tested bursaries for personal support, which does not have to be paid back, and this is financed by the National Health Service.  Two questions arise: 1) is this a fair system?; 2) is this a necessary system?  I contend that the answer to both questions is 'no'.

The system is not fair because it does not apply to other university students who have to pay fees and take out a loan for personal support.  Arguments about the level of fees and the demise of education authority grants for the personal support of students aside, why should nursing students in the UK be supported in this way?  In the USA and Australia, for example, nursing students do not receive such support; they pay fees and support themselves through university education, like any other student.  I suppose a supplementary question is: why do we support nursing students in the UK in this way?

The answer is: I don't really know.  One aspect of the funding of nursing education in the UK, which is now wholly incorporated into universities and now leads to an all graduate entry profession, is that it is funded by the NHS.  This sets it aside from most other university subjects which are funded, for UK students - in addition to the fees they pay - by the Higher Education Funding Councils or equivalent bodies across the four countries of the UK.  I am a strong advocate for breaking this link between the NHS and nursing education, whereby nursing education is commissioned by local bodies which administer the NHS funding, and for nursing education to be funded like other subjects.  One reason for this is that the process does not work: witness the shortage of nurses, the attrition of nursing students and the high dependence of the NHS on overseas nurses.  However, it does not work at the local level where universities essentially 'jump to the tune' of the commissioning bodies who demand increases in nursing education places without, for example, taking any responsibility for providing clinical learning places for those students in the hospitals and the community.

Nursing students 'work' long hours

Another reason given is that nursing students 'work' in the NHS and have less holiday time than other students.  But nursing students do not work in the NHS, they are supernumerary, a principle that was established with the advent of Project 2000 in the late 1980s and which has not changed.  Nursing students may, indeed, work hard while they are in the clinical areas and undertake all manner of unsocial working hours; however, they are not part of the established workforce of the NHS.  In practice, supernumerary status is often breached, but that is beside the point and does not alter the principle.  It is not a justification for bursaries.

Clearly, it is a considerable bonus for nursing students when they enter nursing education not to have to pay fees and to have some guaranteed income, but the logic of this escapes me.  It presents a patronising image of nursing students as being a special case almost unable to negotiate the maze of higher education and students loans, like other students have to do, and that they are not quite like other university students.

The system of funding applies to some aspects of postgraduate education for nurses.  For example, Advanced Nurse Practitioner programmes are funded by the NHS but this takes place locally to address local needs.  At considerable expense, a nurse can be trained as an Advanced Nurse Practitioner over two years, possibly up to masters degree level, qualify and leave that area of the NHS.  While the good of the UK may have been served if that nurse remains in the UK, the money has been wasted by the area of the NHS which funded the training.  Surely another argument, whether money rests with the NHS or not for postgraduate education, for a more centralised planning system based on national and not local need.

Nursing students just do it for the money

A major worry for some academic colleagues and students who have expressed this to me is that some nursing students enter nursing education simply because a bursary is available.  I have heard this often enough for it not to be ignored.  Nevertheless, I realise that 'the plural of anecdote is not data' and that some work is needed to establish how widespread this is.  However, the high attrition of nursing students (anecdotally reported to be 50% in some universities) and the high attrition of nurses in their first year of clinical practice could point to some lack of commitment among some nursing students, actually, to becoming a nurse.

Whatever the reason for the high attrition - and the reasons are hard to identify - the bursary system is not working to maintain students in education and, subsequently, nurses in practice.  I speculate that a nursing education system where nursing students paid for their education and supported themselves like other students may raise the level of commitment to qualifying and remaining in the profession.  I speculate because I realise that attrition rates are also high in the USA and Australia and that this may have a minimal effect on attrition.

Recruitment to nursing programmes and preventing 'good people' from entering the profession

There is some concern that recruitment would suffer without an inducement to enter nursing education.  This is unlikely given that the numbers of applicants vastly exceeds the number of places available on nursing programmes.  Currently, we have to turn away many suitably qualified applicants and make decisions based on spurious grounds such as personal statements and interviews.  The process is expensive as it requires many hours of university and NHS colleagues' time.  If bursaries are the inducement to enter nursing education then ending them may make the numbers of applicants more manageable, and we will definitely see who is committed to nursing over and above the favourable financial inducements.

Keeping 'good people' who may not otherwise apply for nursing education out of the system does not  apply to any other university subject or profession, so why should nursing be hostage to the 'tyranny of niceness'?  Concomitantly, it is worth noting that, until entry to the nursing profession became by degree only in the UK that nurses undertaking degrees were discriminated against; they were not eligible for the non means tested bursary.  This was a clear indication from successive UK governments of all shades about what they preferred and what they and the NHS thought of graduate nurses.  It is interesting to note that places on degree nursing programmes remained universally oversubscribed; the message is that some people do want to do nursing, they do care about having a degree and they are willing to sacrifice to obtain it.