• Niall McCrae

Stop blaming austerity and exploitation for nursing dropouts

In the heated debate raging in Germany on Angela Merkel’s decision to open the door to hordes from distant lands, and the resulting crime surge, I was struck by a proposal from the Green Party. Illegal immigrants, the spokesperson said, should be allowed to stay on condition that they work in elderly care.

Typically naïve Green ideology: to be charitable I’d say ‘they know not what they do’. Forcing restless young blokes from sub-Saharan Africa or the Middle East to wash and feed frail octogenarians is a guarantee of neglect and abuse. Some would take to the work with enthusiasm, many would simply tick the boxes, but inevitably a minority would besmirch the whole project by mistreating or stealing from the vulnerable.

As the media were reporting this really bad idea, I saw a headline in the Independent complaining about a high rate of attrition in nurse training. “One in four nurses drop out before graduating, new research reveals,” screamed the headline. Other British media are also reporting the story.

Why do a quarter of nursing students leave during the course? The Royal College of Nurses promptly shot back with the reasoning that trainees were quitting in droves because they were plagued by financial difficulties and exploited as “cheap labour”. Ah! The good old left-wing tropes of exploitation now rephrased for popular consumption in that great catch-all of ‘austerity’!

Forcing restless young blokes from sub-Saharan Africa or the Middle East to wash and feed frail octogenarians is a guarantee of neglect and abuse.

Certainly there has been a significant change in financing nurse education, with the means-tested bursary replaced by course fees. However, the marked decline in applications may be temporary. Unlike all other students, those who complete a nursing course are guaranteed a £23,000+ salary when they qualify as a registered practitioner, with ample opportunities for career progress. Notice how weak job prospects have not dissuaded young people from doing media studies!

Dropouts are not necessarily voluntary, as the article implies. Lecturing in the nursing faculty of a prestigious Russell Group university, I am continually impressed by our students. Bright, caring, and much more mature than I was at their age, our best students always complete the course. By contrast, the few casualties are often predictable.

According to the Independent, students are under too much pressure, but nurse training is meant to be a test of competence and character. In my experience, the main causes of attrition are not financial (most students do paid care work alongside their training, taking advantage of gaps in the university timetable), but personal problems and academic failure.

Universities and personal tutors have a responsibility to support students in difficulty, but sometimes this is futile. Nurses must be able to count, to read and write, and to communicate effectively – sadly not all students are fully replete with these skills. Disability can be managed and supported (e.g. dyslexia), but it would be dangerous for a practising nurse to be unable to comprehend a clinical instruction or patient’s utterance, or to be unable to calculate a drug dosage.

How are feeble students accepted on to a nursing course? Partly this is a problem of grade inflation in the education system, with certificates not always worth the paper they’re printed on. Academic attainment is not the only criterion; recruits to nurse training should be judged on their motivation and morals.

Realistically, however, it isn’t feasible to conduct lengthy individual interviews with each applicant. As the typical nursing school has an annual intake of three or four hundred, the recruitment process is a compromise with resource constraints. Standards are noticeably lower at some of the former polytechnics, where entry is easier and failing students are allowed multiple re-sits for an essay or practice assessment.

Some readers may be thinking that the system is at fault: why should nursing be taught at university? In fact, 50% of the course entails clinical practice on the wards or in community teams. Consider the complexity of modern nursing, with ever-expanding theory and evidence to apprehend for practice, and the heavy weight of responsibility for patients’ lives.

Ask yourself: if you were recovering from a major operation would you prefer a graduate practitioner fixing your drip or a worker who has good caring qualities but lacks pharmacological knowledge? That is not to suggest that all nursing care requires a degree qualification. There are other routes for the less intellectually endowed: the new nursing associate is a reinvention of the state enrolled nurse, with a lower level of training and status. We always need health care assistants to support the work of qualified staff.

Nurses must be able to count, to read and write, and to communicate effectively – sadly not all students are fully replete with these skills.

One phrase in the Independent article irked me: “cheap labour”. Good students enjoy the opportunity to spend time with patients. Instead of exploitation, it’s a privilege to care for a sick child recovering from meningitis, to reassure a person bewildered by dementia, or to share with a family the last hours of someone’s life.

Good students appreciate that their mentor, the qualified nurse who supervises them, bears responsibility for the patient’s care and any task delegated to a student. My guess is that “cheap labour” is not very good labour, performed by someone who does not convey caring intent.

Like any profession, nursing must set a bar for standards of practice and practitioners. And that means that some who seek entry to the register do not succeed.

(Dr Niall McCrae is a lecturer in mental health, and a writer on social and political affairs. He regularly contributes to The Salisbury Review and Bruges Group website, and has written two books: The Moon and Madness, and Echoes from the Corridors: The Story of Nursing in British Mental Hospitals).