Nurse Education in Practice 14 (2014) 641e647
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Issues concerning recruitment, retention and attrition of student nurses in the 1950/60s: A comparative study Annette M. Jinks a, *, Kathleen Richardson a, 1, Chris Jones b, 2, Jennifer A. Kirton a, 3 a b
Evidence-based Practice Research Centre, Faculty of Health and Social Care, Edge Hill University, UK Faculty of Health and Social Care, Edge Hill University, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 6 July 2014
Aim: To investigate student nurse recruitment and attrition in the 1950' and 1960s and undertake comparisons to modern day concerns. The study was set in one hospital in the UK. Background: In the period studied nursing was unpopular as a profession and there were difficulties surrounding recruitment. Attrition rates were high. Method: Documentary analysis of 641 training records dating 1955 to 1968 was undertaken. Attrition rates, reasons for non-completion and employment following successful completion were determined. Results: Most recruits were young, unmarried, females and had overseas addresses. The majority (n ¼ 88) had prior nursing experience. Over 69% (n ¼ 443) successfully completed their training. Attrition rates were over 30% (n ¼ 198), the main reason being academic failure. Following completion over 40% (n ¼ 183) undertook midwifery training (n ¼ 183) or secured a staff nurse post (n ¼ 153). Conclusions: Issues relating to recruitment, retention and attrition in the 1950s and 1960s put into context present day issues. Recent attrition rates from pre-registration nurse education have fallen, nevertheless some of the issues of yesteryear remain problematic. In the present study significant numbers of entrants left due to domestic and ill-health problems resonates with many modern day studies. Also failure to complete due to academic shortcomings continues to be a concern. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Historical cohort study Nursing student selection and dropout
Introduction This paper concerns a documentary analysis of student nurse records spanning from 1955 to 1968 who were undertaking State Registration Nurse (SRN) training. The study's purpose was to investigate student nurse recruitment and attrition in the 1950' and 1960s and compare to modern day concerns. Attrition in the context of this study is defined as non-completion of a training programme for whatever reason. It was thought the analysis would provide a local historical context to the nurse education provision delivered today by the University where the study was undertaken. Of more general practical value was the analysis would also help
give better understanding of the current issues pertaining to student nurse recruitment, retention and attrition both in the United Kingdom (UK) and internationally. Of relevance to the study was that recruitment and retention of nurses in the 1950s and 1960s was of national concern in the UK. Recruitment of student nurses was often poor. Attrition from nurse training in the 1950s and 1960s was also high. Main reasons for non-completion are identified by Urwin et al. (2010) as being such things as academic failure, leaving due to domestic problems and unsuitability for a career in nursing. Issues such as these remain of concern to nurse educators in modern times.
Background * Corresponding author. Evidence-based Practice Research Centre, Faculty of Health and Social Care, Edge Hill University, St Helen's Road, Ormskirk Lancs L39 4QP, UK. Tel.: þ44 (0)1695 650946. E-mail addresses: [email protected], [email protected] (A.M. Jinks), [email protected] (K. Richardson), [email protected] (C. Jones), [email protected] (J.A. Kirton). 1 Tel.: þ44 (0)1695 657078. 2 Tel.: þ44 (0)151 529 6242. 3 Tel.: þ44 (0)1695 657169. http://dx.doi.org/10.1016/j.nepr.2014.07.002 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
The training records analysed date from a time when apprenticeship models of nurse training was the custom. Kirby (2009) relates that apprenticeship systems had an emphasis on instilling obedience and discipline and nursing practice was characterised by rituals and routines that had been passed down from one generation of nurses to the next. Baly (1980) also describes how there was little theoretical content in nurse training programmes and most
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training took place on the wards where student nurses sometimes learnt in a ‘sitting by nelly’ way but more often simply by trial and error. Goddard (1953) in one of the first analysis of the work of nurses identifies that frequently hospitals were staffed by student nurses, so supervision of student nurses' clinical practice was minimal. Additionally Baly (1980) recounts that nursing research was in its infancy and an inquiring and questioning stance especially amongst student nurses was frowned upon. There were also vocational even religious attributes associated with those pursuing a nursing career. The unpopularity of nursing as a profession and difficulties surrounding recruitment is reported by some authors. For example, Baly (1980) relates that in the early years following the introduction of the NHS (National Health Service) in 1948 there was a ‘woeful shortage of nurses’ (p319). The recruitment of British-born women was poor, as the young and single at the time were more interested in getting better paid jobs such as secretarial work or teaching. As a result in the 1950s the British government had a recruitment drive with a deliberate policy to attract qualified nurses and student nurses often from the former British colonies and particularly the West Indians (Kramer, 2006). There was also a considerable flow of Irish student nurses to England demonstrated in that 95% of the Irish Registered nurses in 1951 had trained in the UK (Yeates, 2009). Attrition from nurse training in the 1950s and 1960s was also high. The term used at the time was ‘wastage’ (Urwin et al., 2010). Whilst many of the expressions used in this paper, such as for example, training instead of education, ward sister instead of ward manager is part of an aim to remain true to the conventions of the time, however, there is a deliberate intention not to use the term wastage. Whilst the term wastage was in common use its negative connotations of failure to complete being a waste of time and perhaps those not completing being a waste of time too, is seen as being unhelpful. As Urwin et al. (2010) relates education is rarely a complete waste of time as the processes that individuals go through to reach conclusions that they are not suitable for nursing is very often a valuable learning experience. Also use of the term wastage does not take into account the trauma, embarrassment and dent in self-esteem that individuals experience when they do not complete their programme (Urwin et al. (2010). Reasons for attrition from nurse training in the 1950s and 1960s are sometimes rather different than they are in present times. For example, marriage accounted for 13% of women who gave up training in the 1950 and 1960s and more men withdrew than women because of insufficient salary (O'Dowd, 2008). However, some reasons were similar to those experienced today. For example, withdrawals from training in the first year were most likely to be for educational reasons such as examination failure. Today academic failure continues to be a major reason of why students do not complete their programme (Cameron et al., 2011). Historically many withdrew because of the unsocial hours they were expected to work, poor accommodation and arbitrary and often petty regulations they were subjected to both on the wards and in their leisure time. As Baly (1980) reports there was also a constant conflict between the meeting the educational needs of student nurses and the staffing needs of the hospital. A situation that is sometimes reported by student nurses today (Thomas et al., 2011). Often the only support student nurses had at the time was that of their ‘own set’ or those in the same cohort. A similar scenario is described by Roberts (2009) in a study of present day preregistration student nurses. The attitudes of ward sisters and their individual temperaments were often the causes of anxiety and stress. ‘Good’ ward sisters of the time could mean the difference between life and death of patients, whereas ‘poor’ sisters could result in very unpleasant and stressful clinical experiences for student nurses (Reid, 1985).
Table 1 Sample characteristics (n ¼ 641). Topic
Categories
Frequencies
Percentages
Year of entry
1955e1960 1961e1965 1965e1968 Missing data Under 21 years 21e30 years 31e40 years Over 41 years Missing data Male Female Single Married Divorced Widowed Missing data England (Merseyside) Scotland Northern Ireland Wales None UK Missing data Eire Caribbean Nigeria Mauritius Cameroon Ghana
267 299 74 1 497 120 17 4 3 53 688 603 21 0 1 16 245 (232) 1 7 15 371 2 350 8 5 3 1 1
41.6% 46.6% 11.5%
Age
Sex Marital status
Home address at entry
Home address of non-UK recruits
77.5% 18.7% 2.6% 0.6% 8.3% 91.7% 96.5% 3.4% 0 0.2% 38.3% (36.1%) 0.2% 1.1% 2.3% 58.1% 54.6% 1.25% 0.8% 0.5% 0.2% 0.2%
It may be concluded from this albeit brief overview of recruitment, retention and attrition issues, whilst there are some similarities in issues that face nurse educationists today and their colleagues of nearly 60 years, there are also differences. Often these relate to differences in the wider social world and healthcare environments of the time. It is with this as a backdrop that analysis of the nurse training records was undertaken. Methods The purpose of the study was to investigate student nurse recruitment and attrition in the 1950' and 1960s and compare to modern day problems. The study objectives were to: 1. Investigate the characteristics of student nurses recruited in the 1950s and 1960s to a large acute hospital in the Liverpool area of the North West of England. 2. Identify reasons why student nurses left their training programmes early. 3. Examine what the first employment of nurses was when they had qualified. 4. Compare the findings of the training records analysis with current national and international literature on the subject area.
Design In essence the study was a documentary analysis of some historical records. That is three large files of nurse training records dated from 1955 to 1968 containing 641 individual records were available for analysis. Analysis of the data took place in 2013. Data extraction The records were in good condition and contained mostly individual hand written accounts of a student nurse's entry details
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and progress during training and usually spanned two or three A4 size pages. Information such as the person's date of birth, sex, marital status, previous occupation and home address at the point of entry to nurse training was noted. Also recorded were major training events such as completion of preliminary, hospital and state final examinations. Reasons and dates of leaving as well as details of the person's next post were also usually given. Data analysis Content analysis approaches as described by Krippendorff (2004) were utilised to extract data from the training records. Content analysis is a commonly used research method for systematically analysing documents as it is useful for looking for trends and patterns in documents (Elo et al., 2008). Whilst there are a number of different types of content analysis the type used in this research is largely descriptive and deductive in approach (Sarantakos, 2005). That is a ‘bottom down’ approach was used whereby a data framework developed in pilot study work was used. The pilot study work involved initial analysis of 50 of the records by the first and third researchers. From this initial analysis the data framework was developed and used for the remainder of the data extraction which was undertaken by the first and last author. The data framework used is displayed in Tables 1e4. Random checks on the accuracy of the data extracted were undertaken by a third author. Data were then analysed by the third researcher with descriptive statistics such as frequencies, percentages and measures of central tendency being ascertained.
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Table 3 Details of unsuccessful completions. Topic Unsuccessful completion rates Length of time the unsuccessful stayed
Reasons given for unsuccessful completion
Category
1e3 months 4e12 months 13e24 months 25e36 months Over 37 months Failed preliminary examinations Domestic reasons Ill-Health Couldn't cope with the theory, transferred to SEN course Failed State final examinations Did not like nursing/could not cope with the reality of nursing Unsuitable for nursing Left to get married Not known (didn't return to duty) Pregnancy Transferred to another hospital to continue training Emigrated Missing data
Frequency
Percentage
198
30.9%
63 47 45 25 18 52
31.3% 23.95 22.9% 12.9% 8.9% 26.2%
21 21 19
10.6% 10.6% 9.5%
18 16
9.1% 8.1%
14 10 6
7.1% 5.1% 3.0%
2 2
1.0% 1.0%
1 16
0.5% 9%
Results
Ethical considerations The records analysed are now housed at the Liverpool Records Office. Previously they had been stored at the University where the original nurse training school had been sited. Permission to undertake the study was obtained from the University ethics committee. The hospital the training records pertained to has now closed and its facilities had been transferred to one of the North West's of England's large acute NHS Trusts. The data protection officer at this Trust was also contacted and gave permission for the analysis to proceed. Other ethical considerations related to the sensitivity of the information recorded in the records. It is thought that many of the individuals whose details were recorded could still be alive although in their 60s, 70s or even 80s. Most would be retired although a few could still be working. Ethical advice was given that caution about confidentiality and anonymity issues was needed. Therefore data extracted was assigned a case number so that the identities of the individuals were protected. Such things as secure storage of the files was ensured and password protected computers were also used.
As previously related there were 641 individual student nurse training records available for analysis. Years when the individuals entered their nurse training programme dated from 1955 to 1968 with over 46% (n ¼ 299) of the records relating to the 1961e1965 period. Nearly 92% of the recruits (n ¼ 688) were females with slightly over 8% (n ¼ 53) being male. Over 77% (n ¼ 497) were under 21 years old with less than 1% (n ¼ 4) being over 40 years old. The vast majority were unmarried (n ¼ 603). The greater part (n ¼ 371) had overseas addresses with almost 55% (n ¼ 350) originating from Southern Ireland. Local recruitment from the Liverpool area represented only 36% (n ¼ 232) of the total sample group. Table 1 gives further details of these findings. The records also gave the previous occupation of the recruits although it was found that there was a substantial proportion of missing data. That is 277 of the records did not note the recruits'
Table 4 Details of successful completions. Topic
Table 2 Previous occupation (n ¼ 641). Category
Frequency
Percentage
Nursing-type occupation Clerical Cadet nurse Student nurse at another hospital School Shop assistant Domestic work Manual work Factory work Teaching Nun Missing data
88 72 48 34 36 29 29 12 11 3 2 277
13.7% 11.2% 7.4% 5.3% 5.6% 4.5% 4.5% 1.8% 1.7% 0.4% 0.3%
Successful completion rates Intentions
Missing data
Category
Midwifery training Staff nurse post Marriage Returned to mental health nursing Undertake a further nurse training programme Emigrated Left nursing due to illness/domestic problems Not offered a post Left nursing for another occupation
Frequency
Percentage
443
69.1%
183 153 18 11
41.3% 34.5% 4.1% 2.5%
10
2.2%
6 5
1.4% 1.1%
3 2
0.7% 0.5%
52
11.7%
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previous occupation. Where the recruits' previous occupation was documented it was found that the majority (n ¼ 88) had a nursingtype background. Included were backgrounds in mental health, ‘chronic’, orthopaedic and fever nursing as well as those who had previously been enrolled nurses and auxiliary nurses. Others had been cadet nurses at the hospital the records pertained to (n ¼ 48). Some were also recorded as previously being a student nurse who had started their training elsewhere (n ¼ 34). Clerical (n ¼ 72), shop (n ¼ 29) and domestic work (n ¼ 29) dominated the non-nursing type occupational groups. Only a small number (n ¼ 36) were recorded as being at school prior to their recruitment. Table 2 gives further details of these findings. It was found that over 69% (n ¼ 443) of the student nurses had successfully completed their training. There was a sizeable amount of missing data (n ¼ 52) concerning what the intentions of the successful completers were. However, the majority were reported as intending to undertake their midwifery training (n ¼ 183), take up a staff nurse post (n ¼ 153), return to mental health nursing (n ¼ 11) or undertake some other form of further nurse training. Examples here included further training in tropical, theatre, intensive care and casualty nursing. A small proportion were documented as going to leave nursing altogether to get married (n ¼ 18), or that they were leaving due to domestic problems (n ¼ 5) or to take up another occupation (n ¼ 2). For example, one of the very few male nurses who completed their training was said to want to return to their previous job as a builder as the pay was substantially better, whereas another female nurse was leaving nursing to be a nun. A tiny amount (n ¼ 3) were said not to have been offered a post and had been asked to leave despite successfully completing their programme. Table 4 gives further details of the first employment of those who successfully completed their training. Concerning details of attrition from the training school it was found that over 30% (n ¼ 198) did not complete their training with the majority leaving within the first three months (n ¼ 63) of the programme. However, some (n ¼ 18) were found to continue with their training for over 37 months before leaving. Four people were recorded as leaving at 49e60 months after repeated failed attempts at their state final examinations. The main reasons given for unsuccessful completion were because the student nurses failed their preliminary training school/preliminary examinations (n ¼ 52). Domestic reasons (n ¼ 21) and ill-health (n ¼ 21) were also relatively frequently cited reasons. Examples here included students who returned home to Ireland to look after sick relatives or some who had suffered severe home-sickness. A number were reported as not being able to cope with theory and had been transferred to an enrolled nurse (EN) training programme (n ¼ 19). Several were said not to like nursing (n ¼ 16) or that they were unsuitable for nursing (n ¼ 14). Unsuitability was often couched in terms of the student being ‘useless’, ‘poor practically’ ‘lazy and indifferent to the needs of patients’ ‘selfish and irresponsible’ or ‘rude with little respect for senior staff’. Finally a few left to get married (n ¼ 10) or because they were pregnant (n ¼ 2). For example, one person was said to find ‘marriage more attractive option than nurse training’. Table 3 gives further details of these findings. Discussion Limitations of this study include such things as the relatively small number of the nurse training records analysed. The local nature of the material is a further limitation. However, the study does help to illuminate and put into context some present day dilemmas surrounding the recruitment and retention of nurses. Using a historical lens there are a number of lessons that nurse educators today can learn from the findings of the study conducted.
These are more fully discussed in the following sections of this paper. As related earlier recruitment and retention of nurses in the 1950s and 1960s was of national concern in the UK. Recruitment of student nurses was often poor. As a result in the 1950s there was a deliberate policy to attract qualified nurses and student nurses from the former British colonies and particularly the West Indies (Kramer, 2006). This is not reflected in data analysis undertaken as it was found only just over 1% of the student nurses had a Caribbean home address. However, it might explain why there was seemly poor local recruitment with only just only 36% of the records noting a local Liverpool address. It may also explain why over half the sample was recruited from Southern Ireland although as Yeates (2009) relates there may be other reasons in play. For example, nurses of this generation enjoyed high social esteem in Ireland with nursing as a profession being associated with middle-class status. As a result there was a considerable flow of Irish student nurses to England demonstrated in that 95% of the Irish Registered nurses in 1951 had trained in the UK (Yeates, 2009). Britain was a popular destination for training due to free right of access, cultural and linguistic similarities, available employment and frequent and inexpensive transport links. The downside was as Baly (1980) describes was that although immigrants were helping to keep the British health services afloat it was unlikely that all would be a permanent addition to the workforce. Thus immigrant recruitment was likely to perpetuate cycles of shortage of trained nurses. A situation Baly (1980) relates as being unhelpful to the immigrant staff as it was to the hospital authorities of the period. Similarly in more recent times a shortage of trained nurses in the UK has resulted in employment of immigrant staff to cover the shortfall. For example, Donnelly (2013) identifies that the numbers of foreign nurses coming to Britain to work has doubled over recent years. NHS hospitals are also thought by Donnelly to be ‘poaching’ nurses from countries who can ill afford to lose their trained staff as they have major health issues of their own. In the UK shortages of trained nurses can often be traced to national and local inadequacies in commissioning of student nurse education numbers. The resultant cycle of glut and lean years of numbers of trained nurses available for employment seems to be a situation that is never dealt with satisfactorily and lessons from the past have not been acted upon (Taylor et al., 2010). Analysis of the training records also shows that the personal characteristics of the student nurses the records pertain to is not dissimilar to what is reported in the literature relating to the time. Kirby (2009) for example, in an analysis of archival and oral sources relating to training in the 1940s indicates that the majority of recruits at the time were young, unmarried, women for whom hospitals took on a ‘loco parentis’ role. The main incumbent of this role were hospital matrons. The restrictions imposed on the student nurses related to how seriously this responsibility was viewed by many matrons. As described earlier a student nurse's life was often governed by petty regulations imposed both on the wards and also during off-duty leisure time. That nurse training in the 1950/60s was paternalistic and anachronistic and in being so failed to reflect trends in the wider society which were directed at increasing civil rights, feminism and liberalism. The recruitment profile of student nurses usually being young single women largely continued to be the case in the 1950s and 1960 (Singh and Smith, 1975). However, by the 1970s and 1980s there was increasing concern that the rapidly changing demography of the UK would result in a depleted pool of potential young recruits. Indeed Houltram (1996) reports integral to the introduction of Project 2000 in the 1980s and 1990s was a desire to widen
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access to nurse education so as to include greater proportions of males and mature students in the student body. Prior to this time the incidence of male nurse recruits was usually small in number, apart from in specialities such as mental health nursing. This is again is reflected in findings of the analysis with less than 8% of the records relating to male student nurses. It is also borne out by the more general position of male nurses. For example, it was not until 1960 that the Royal College of Nursing (RCN) in the UK changed its charter and admitted men (Whittock and Leonard, 2003). Societal taboos in many of the developed nations were also slow to change and it was not until later decades that nursing became less related with ‘women's work’ and associated negative gender stereotypes (Jinks and Bradley, 2003). (The term developed nations meant to imply a country that has a highly developed economy and advanced technological infrastructure relative to other less developed nations.) Similarly mature students and particularly older married women were not actively recruited as student nurses. Whilst marriage and nursing were not very compatible as it was a requirement for students to live-in the nurses' home it was however, also in line with the social norms of the time when married women's primary roles were seen as being homemakers and child rearers (Tilly and Scott, 1987). Failure of many of the records to give the previous occupation of the recruits is thought probably due to the fact that most did not have a previous occupation as they were an age when they were likely to be still at school. Being at school was likely not to be classified as a previous occupation by the record keepers. However, where previous employment details were given the propensity for the recruits to have some nursing-type experience is very similar to what forms of part of recruitment criteria deployed today by many nurse education institutions. For example, in more recent times in the UK interviews remain an important part of nurse education recruitment strategies with recruits needing to show that they have some insight into the realities of nursing as a profession (Karstadt, 2011). The importance of this is underlined in the present analysis in that successfully completing the programme was significantly related to those who had previous nursing type employment. Nursing as stressful and demanding is well-reported with authors such as Glossop (2001) relating the difficulties many students have coping with clinical practice and the impact this has on today's student nurse attrition rates. This is an issue that is not solely UK related with authors from many other countries reporting similar concerns (Clark and Springer, 2007; Elliot, 2002; Ralph et al., 2009). The nearly 31% attrition rate identified from analysis of the training records was by no means unusual at the time. For example, Baly (1980) reports a national average of 39% attrition from nurse training in 1961 with some hospitals having attrition rates of well over 50%. In more recent times attrition rates from pre-registration nurse education are generally less. For example, Andrews et al. (2005) in a comparative study involving two UK universities found attrition rates from 1997 to 2000 was 17.7%, whereas Mulholland et al. (2008) in a longitudinal cohort study identifies an attrition rate of 22% and Kevern et al. (1999) identifies a 25% attrition rate in their study. Nevertheless some international studies suggest that the UK may still have comparably high attrition rates. For example, in Australia an investigation which began in 1999 found attrition from nurse education programmes to be only 7% (The National Nursing and Nurse Education Taskforce, 2005). These and similar findings need, however to be viewed with caution as accurate calculation of nurse education attrition rates is reported by a number of authors to be notoriously difficult. For example, Glossop (2001) highlights the complex methodological issues involved in measuring nursing student attrition rate with use of a comparable format and an agreed definition of attrition being
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problematic. Such things as databases not tracking individuals who change courses, or who had deferred their studies or changed to part time modes of study are some of the difficulties identified by Glossop (2001). A natural progression from consideration of nurse education attrition rates leads to exploration of why some leave without successfully completing their studies. Analysis of the training records shows academic failure to be the primary reason why many did not complete their training. Whilst a number of training records analysed describe student nurses as being ‘dull’ or ‘not scholarly up to SRN training’ they give no indication of their academic backgrounds prior to recruitment. However, for those with a nonnursing type occupational background most had jobs that at the time only needed modest educational qualifications, if any at all. For example, analysis of the training records show only one person gave teaching as their previous occupation whereas the majority were engaged in factory, shop, clerical or manual work. The Platt Report (RCN, 1964) sets out what many of the time considered the heart of the problem and was likely to be the case in the training records analysed. ‘All those who wish to nurse and who were prepared to be persistent in seeking admission to general training were likely to be accepted, if not for the hospital of their first choice then in some other hospital which was short of staff’ (p6, para 17). The Platt Report (RCN, 1964) recommended that the standard entry to nurse training should be five subjects at General Certificate of Secondary Education (GCE) level (Ousey, 2011). (The GCE was first introduced in England and Wales in 1951 as a type of school leaving certificate in a variety of subjects. It had examinations graded into ordinary levels, ‘O-Levels’, for the top 25% and (from 1965) Certificate of Secondary Education (CSE) for lower attaining pupils.) However, as White (1985) relates when the minimum education level for entrants to nurse training was reinstituted in 1962 the entry level was set at two GCEs and remained so after the findings of the Platt report were published. Nevertheless, the General Nursing Council (GNC) continued to express the opinion that lack of standard entry criteria in many UK hospitals was the paramount cause of high attrition (MacGuire, 1969) and as a consequence student nurses studying at the time often could not cope with the requirements of the nursing syllabus. This is borne out in the present analysis where it was found that some left in the first months of their training due to failing their preliminary examinations. Indeed the analysis revealed a surprising number of students continued with their training for as long as four and five years only to eventually leave after failing their state finals examinations after repeated attempts. Clearly the level of nurse education today is higher than that of the time of the training records with graduate entry to the profession being the norm for many nations. (Graduate entry means completion of an undergraduate programme prior to nurse registration.) This has certainly through time given rise to re-evaluation of academic entry criteria in many countries. For example, in the UK whilst there are no national minimum entry requirements for pre-registration nurse education candidates must be able to demonstrate evidence of literacy and numeracy skills (Nursing and Midwifery Council (NMC) 2004). Nevertheless most UK universities that offer nurse education programme set their entry criteria at a minimum of five GCSEs and ‘A’ level study or equivalent for entry to undergraduate programmes being customary. (A-levels studies normally follow on after GCE examinations and are pre-university examinations in three or four subject areas studied over a two-year period.) This level of education attainment is similar to many other countries. For example, in the United States (US) whilst it retains multiple entry levels to nurse education programmes, many programmes
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are at undergraduate or masters level and have entry criteria similar to those of other US university programmes (Workforce and Training Taskforce, 2007). Despite raising academic entry criteria for nurse education in the UK it is disheartening to relate that a number of authors report attrition due to academic failure continues to be one of the main reasons why students leave without completing their programme of study (Glossop, 2001). Some also identify that younger students with only modest academic achievement are at most risk of unsuccessful completion (Buchan and Semour, 2004), a profile not dissimilar to those that many of the nurse records pertain to. It would seem that some of the issues of yesterday continue to remain problematic today and leads to recommendations that careful monitoring is needed of the progress of those with only modest educational attainments. Likewise that substantial number of entrants whose records were analysed left due to domestic and ill health problems resonates with many of modern day studies. For example, Kevern and Webb (2004) investigated the needs of mature students and found whilst many seemed to be more motivated than younger students and appeared better able to study independently they did have specific problems which may need addressing. These are related to various issues amongst which may be finance problems and family commitments. Recommendations that arise out of these findings relate to having in place robust student support systems and counselling services. The final area of the nurse training records analysis concerns the first destination of those who successfully completed their programme. It was shown that most stayed at the hospital where they had trained with the majority being appointed to staff nurse posts or going on to undertake their midwifery training. A national shortage of nurses in the UK in the 1960s meant there was little fear of not being able to get a post (Kirby, 2009). This contrasts vividly to the position that many newly qualified nurses in the UK and other countries find themselves in today. For example, in recent years uncertain economic times and reductions in the demand for nurses by the NHS which is the main employer of nurses in the UK has meant there has generally been a reduction in the numbers of registered nurses over the last few years. As Buchan and Semour (2010) report from the findings of a UK nursing labour force review there are of signs of redundancies and recruitment freezes emerging in some parts of the NHS, particularly in England. These dilemmas are not confined in the UK as many countries are facing economic constraints which will no doubt prove to result in recruitment and retention difficulties both for the profession and many newly qualified nurses. Conclusions It is concluded that the findings of this study serve as a reminder of how historical analysis can illuminate and put into context present day dilemmas. It is perhaps salutary to note that many of the recruitment and retention issues facing the nursing profession today are not new as many are similar to those reported in the 1950s and 1960s. For example, whilst recruitment of males, mature students and particularly older married women has improved over time there is still room to further increase their numbers and help solve some present day recruitment issues. Similarly whilst some improvements in retention have been achieved it is still unacceptability high when UK rates are likened to other countries. Unsuccessful completion due to academic failure is an area that remains problematic and needs further deliberation. Whilst attrition in the UK is obviously a concern to both universities and NHS manpower planners it should not be overlooked that unsuccessful completion also comes with a personal cost. Whilst there will
always be some that are unsuited for a career in nursing, the trauma, embarrassment and dent in self-esteem that individuals experience when they fail to complete their programme should not be forgotten. References Andrews, G., Andrews, J., Brodie, D., Rixon, L., Thomas, B., 2005. Place(ment) matters: students' clinical experiences and their preferences for first employers. Int. Nurs. Rev. 52 (2), 142e153. Baly, M., 1980. Nursing and Social Change, second ed. William Heinemann Medical Book, London. Buchan, J., Semour, I., 2004. Fragile Future? A Review of the UK Nursing Labour Market in 2003. Royal College of Nursing, London. Buchan, J., Semour, I., 2010. Sustaining the Long View. The UK Nursing Labour Market Review 2010. Royal College of Nursing, London. Cameron, J., Roxburgh, M., Taylor, J., Lauder, W., 2011. An integrative literature review of student retention in programmes of nursing and midwifery; why do students stay. J. Clin. Nurs. 20 (9e10), 1372e1382. Clark, C.M., Springer, P.J., 2007. Incivility in nursing education: a descriptive study of definitions and prevalence. J. Nurs. Educ. 45 (1), 7e14. Donnelly, L., 2013. Number of foreign nurses coming to the UK doubles in three years as the NHS poaches workers from abroad. The Telegraph 45. October 14th. Elliot, M., 2002. The clinical environment: a source of stress for undergraduate nurses. Aust. J. Adv. Nurs. 20 (1), 34e38. Elo, S., Kyng€ as, H., 2008. The qualitative content analysis process. J. Adv. Nurs. 62 (1), 107e115. Glossop, C., 2001. Student nurse attrition from pre-registration courses: investigating methodological issues. Nurse Educ. Today 21 (3), 170e180. Goddard, H.A., 1953. The Work of Nurses in Hospital Wards: Report of a Job Analysis. Nuffield Provincial Hospitals Trust. Houltram, B., 1996. Entry age, entry mode and academic performance on a Project 2000 common foundation programme. J. Adv. Nurs. 23 (6), 1089e1097. Jinks, A.M., Bradley, E., 2003. Angel, handmaiden, battleaxe or whore? A study which examines changes in newly recruited student nurses' attitudes to gender and nursing stereotypes. Nurse Educ. Today 21 (2), 121e127. Karstadt, L., Sept 22nd, 2011. The future of nurse training: can unsuitable students be identified? Br. J. Nurs. 20 (17), 1143. Kevern, J., Webb, C., 2004. Mature women's experiences of preregistration nurse education. J. Adv. Nurs. 45 (3), 297e306. Kevern, J., Ricketts, C., Webb, C., 1999. Pre-registration diploma students: a quantitative study of entry characteristics and course outcomes. J. Adv. Nurs. 30 (4), 785e795. Kirby, S., 2009. Recruitment, retention and representation of nurses: an historical perspective. J. Clin. Nurs. 18 (20), 2725e2731. Kramer, A., 2006. Many Rivers to Cross: Caribbean People in the NHS 1948e69. Stationery Office, London. Krippendorff, K., 2004. Content Analysis; Introduction to its Methodology. Sage, London. MacGuire, J., 1969. Threshold of Nursing. Bell & Sons, London. Mulholland, J., Anionwue, N., Atkins, R., Tappern, M., Franks, P., 2008. Diversity, attrition and transition into nursing. J. Adv. Nurs. 64 (1), 49e59. Nursing, Midwifery and Health Visiting Council, 2004. Standards of Proficiency for Preregistration Nursing Education retrieved from. http://www.nmc.org/Documents/ Standards/nmcStandardsofProficiencyForPreRegistrationNursingEducation. on December 12th 2012. Ousey, K., 2011. The changing face of student nurse education and training programmes. Wounds UK 7 (1), 70e76. O'Dowd, A., Jan 8e14, 2008. NHS Nursing in the 1950s. Nursing Times 104 (1), 20e22. Ralph, E., Walker, K., Wimmer, R., 2009. Practicum and clinical experiences: postpracticum students' views. J. Nurs. Educ. 48 (8), 434e440. Reid, N.G., 1985. Wards in Chancery? Nurse Training in the Clinical Area. Royal College of Nursing, London. Roberts, D., 2009. Friendship fosters learning: the importance of friendships in clinical practice. Nurse Educ. Pract. 9 (6), 367e719. Royal College of Nursing, 1964. A Reform of Nurse Education (The Platt Report). RCN, London. Sarantakos, S., 2005. Social Research, third ed. Macmillan Education, Melbourne. Singh, A., Smith, J., 1975. Retention and withdrawal of student nurses. Int. J. Nurs. Stud. 12 (1), 43e56. Taylor, J., Irvine, F., Bradbury-Jones, C., McKenna, H., 2010. On the precipice of great things: the current state of UK nurse education. Nurse Educ. Today 30 (3), 239e244. The National Nursing and Nurse Education Taskforce, 2005. N3ET Myth Busters. Retrieved from. http://www.rcna.org.an. on December 12th 2012. Thomas, J., Jack, B., Jinks, A.M., 2011. A systematic review and meta synthesis of adult branch student nurses' clinical experiences; Resilience to care. Nurse Educ. Today 32 (6), 657e664. Tilly, J., Scott, W., 1987. Women, Work, and Family. New York & London, Methuen. Urwin, S., Stanley, R., Jones, M., Gallagher, A., Wainwright, P., Perkins, A., 2010. Understanding student nurse attrition: learning from the literature. Nurse Educ. Today 30 (2), 202e207.
A.M. Jinks et al. / Nurse Education in Practice 14 (2014) 641e647 White, R., 1985. Educational entry requirements for nurse registration: an historical perspective. J. Adv. Nurs. 10 (6), 583e590. Whittock, M., Leonard, T., 2003. Stepping outside the stereotype. A pilot study of the motivations and experiences of males in the nursing profession. J. Nurs. Manag. 11 (4), 242e249.
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Issues concerning recruitment, retention and attrition of student nurses in the 1950/60s: A comparative study Annette M. Jinks a, *, Kathleen Richardson a, 1, Chris Jones b, 2, Jennifer A. Kirton a, 3 a b
Evidence-based Practice Research Centre, Faculty of Health and Social Care, Edge Hill University, UK Faculty of Health and Social Care, Edge Hill University, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 6 July 2014
Aim: To investigate student nurse recruitment and attrition in the 1950' and 1960s and undertake comparisons to modern day concerns. The study was set in one hospital in the UK. Background: In the period studied nursing was unpopular as a profession and there were difficulties surrounding recruitment. Attrition rates were high. Method: Documentary analysis of 641 training records dating 1955 to 1968 was undertaken. Attrition rates, reasons for non-completion and employment following successful completion were determined. Results: Most recruits were young, unmarried, females and had overseas addresses. The majority (n ¼ 88) had prior nursing experience. Over 69% (n ¼ 443) successfully completed their training. Attrition rates were over 30% (n ¼ 198), the main reason being academic failure. Following completion over 40% (n ¼ 183) undertook midwifery training (n ¼ 183) or secured a staff nurse post (n ¼ 153). Conclusions: Issues relating to recruitment, retention and attrition in the 1950s and 1960s put into context present day issues. Recent attrition rates from pre-registration nurse education have fallen, nevertheless some of the issues of yesteryear remain problematic. In the present study significant numbers of entrants left due to domestic and ill-health problems resonates with many modern day studies. Also failure to complete due to academic shortcomings continues to be a concern. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Historical cohort study Nursing student selection and dropout
Introduction This paper concerns a documentary analysis of student nurse records spanning from 1955 to 1968 who were undertaking State Registration Nurse (SRN) training. The study's purpose was to investigate student nurse recruitment and attrition in the 1950' and 1960s and compare to modern day concerns. Attrition in the context of this study is defined as non-completion of a training programme for whatever reason. It was thought the analysis would provide a local historical context to the nurse education provision delivered today by the University where the study was undertaken. Of more general practical value was the analysis would also help
give better understanding of the current issues pertaining to student nurse recruitment, retention and attrition both in the United Kingdom (UK) and internationally. Of relevance to the study was that recruitment and retention of nurses in the 1950s and 1960s was of national concern in the UK. Recruitment of student nurses was often poor. Attrition from nurse training in the 1950s and 1960s was also high. Main reasons for non-completion are identified by Urwin et al. (2010) as being such things as academic failure, leaving due to domestic problems and unsuitability for a career in nursing. Issues such as these remain of concern to nurse educators in modern times.
Background * Corresponding author. Evidence-based Practice Research Centre, Faculty of Health and Social Care, Edge Hill University, St Helen's Road, Ormskirk Lancs L39 4QP, UK. Tel.: þ44 (0)1695 650946. E-mail addresses: [email protected], [email protected] (A.M. Jinks), [email protected] (K. Richardson), [email protected] (C. Jones), [email protected] (J.A. Kirton). 1 Tel.: þ44 (0)1695 657078. 2 Tel.: þ44 (0)151 529 6242. 3 Tel.: þ44 (0)1695 657169. http://dx.doi.org/10.1016/j.nepr.2014.07.002 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
The training records analysed date from a time when apprenticeship models of nurse training was the custom. Kirby (2009) relates that apprenticeship systems had an emphasis on instilling obedience and discipline and nursing practice was characterised by rituals and routines that had been passed down from one generation of nurses to the next. Baly (1980) also describes how there was little theoretical content in nurse training programmes and most
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training took place on the wards where student nurses sometimes learnt in a ‘sitting by nelly’ way but more often simply by trial and error. Goddard (1953) in one of the first analysis of the work of nurses identifies that frequently hospitals were staffed by student nurses, so supervision of student nurses' clinical practice was minimal. Additionally Baly (1980) recounts that nursing research was in its infancy and an inquiring and questioning stance especially amongst student nurses was frowned upon. There were also vocational even religious attributes associated with those pursuing a nursing career. The unpopularity of nursing as a profession and difficulties surrounding recruitment is reported by some authors. For example, Baly (1980) relates that in the early years following the introduction of the NHS (National Health Service) in 1948 there was a ‘woeful shortage of nurses’ (p319). The recruitment of British-born women was poor, as the young and single at the time were more interested in getting better paid jobs such as secretarial work or teaching. As a result in the 1950s the British government had a recruitment drive with a deliberate policy to attract qualified nurses and student nurses often from the former British colonies and particularly the West Indians (Kramer, 2006). There was also a considerable flow of Irish student nurses to England demonstrated in that 95% of the Irish Registered nurses in 1951 had trained in the UK (Yeates, 2009). Attrition from nurse training in the 1950s and 1960s was also high. The term used at the time was ‘wastage’ (Urwin et al., 2010). Whilst many of the expressions used in this paper, such as for example, training instead of education, ward sister instead of ward manager is part of an aim to remain true to the conventions of the time, however, there is a deliberate intention not to use the term wastage. Whilst the term wastage was in common use its negative connotations of failure to complete being a waste of time and perhaps those not completing being a waste of time too, is seen as being unhelpful. As Urwin et al. (2010) relates education is rarely a complete waste of time as the processes that individuals go through to reach conclusions that they are not suitable for nursing is very often a valuable learning experience. Also use of the term wastage does not take into account the trauma, embarrassment and dent in self-esteem that individuals experience when they do not complete their programme (Urwin et al. (2010). Reasons for attrition from nurse training in the 1950s and 1960s are sometimes rather different than they are in present times. For example, marriage accounted for 13% of women who gave up training in the 1950 and 1960s and more men withdrew than women because of insufficient salary (O'Dowd, 2008). However, some reasons were similar to those experienced today. For example, withdrawals from training in the first year were most likely to be for educational reasons such as examination failure. Today academic failure continues to be a major reason of why students do not complete their programme (Cameron et al., 2011). Historically many withdrew because of the unsocial hours they were expected to work, poor accommodation and arbitrary and often petty regulations they were subjected to both on the wards and in their leisure time. As Baly (1980) reports there was also a constant conflict between the meeting the educational needs of student nurses and the staffing needs of the hospital. A situation that is sometimes reported by student nurses today (Thomas et al., 2011). Often the only support student nurses had at the time was that of their ‘own set’ or those in the same cohort. A similar scenario is described by Roberts (2009) in a study of present day preregistration student nurses. The attitudes of ward sisters and their individual temperaments were often the causes of anxiety and stress. ‘Good’ ward sisters of the time could mean the difference between life and death of patients, whereas ‘poor’ sisters could result in very unpleasant and stressful clinical experiences for student nurses (Reid, 1985).
Table 1 Sample characteristics (n ¼ 641). Topic
Categories
Frequencies
Percentages
Year of entry
1955e1960 1961e1965 1965e1968 Missing data Under 21 years 21e30 years 31e40 years Over 41 years Missing data Male Female Single Married Divorced Widowed Missing data England (Merseyside) Scotland Northern Ireland Wales None UK Missing data Eire Caribbean Nigeria Mauritius Cameroon Ghana
267 299 74 1 497 120 17 4 3 53 688 603 21 0 1 16 245 (232) 1 7 15 371 2 350 8 5 3 1 1
41.6% 46.6% 11.5%
Age
Sex Marital status
Home address at entry
Home address of non-UK recruits
77.5% 18.7% 2.6% 0.6% 8.3% 91.7% 96.5% 3.4% 0 0.2% 38.3% (36.1%) 0.2% 1.1% 2.3% 58.1% 54.6% 1.25% 0.8% 0.5% 0.2% 0.2%
It may be concluded from this albeit brief overview of recruitment, retention and attrition issues, whilst there are some similarities in issues that face nurse educationists today and their colleagues of nearly 60 years, there are also differences. Often these relate to differences in the wider social world and healthcare environments of the time. It is with this as a backdrop that analysis of the nurse training records was undertaken. Methods The purpose of the study was to investigate student nurse recruitment and attrition in the 1950' and 1960s and compare to modern day problems. The study objectives were to: 1. Investigate the characteristics of student nurses recruited in the 1950s and 1960s to a large acute hospital in the Liverpool area of the North West of England. 2. Identify reasons why student nurses left their training programmes early. 3. Examine what the first employment of nurses was when they had qualified. 4. Compare the findings of the training records analysis with current national and international literature on the subject area.
Design In essence the study was a documentary analysis of some historical records. That is three large files of nurse training records dated from 1955 to 1968 containing 641 individual records were available for analysis. Analysis of the data took place in 2013. Data extraction The records were in good condition and contained mostly individual hand written accounts of a student nurse's entry details
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and progress during training and usually spanned two or three A4 size pages. Information such as the person's date of birth, sex, marital status, previous occupation and home address at the point of entry to nurse training was noted. Also recorded were major training events such as completion of preliminary, hospital and state final examinations. Reasons and dates of leaving as well as details of the person's next post were also usually given. Data analysis Content analysis approaches as described by Krippendorff (2004) were utilised to extract data from the training records. Content analysis is a commonly used research method for systematically analysing documents as it is useful for looking for trends and patterns in documents (Elo et al., 2008). Whilst there are a number of different types of content analysis the type used in this research is largely descriptive and deductive in approach (Sarantakos, 2005). That is a ‘bottom down’ approach was used whereby a data framework developed in pilot study work was used. The pilot study work involved initial analysis of 50 of the records by the first and third researchers. From this initial analysis the data framework was developed and used for the remainder of the data extraction which was undertaken by the first and last author. The data framework used is displayed in Tables 1e4. Random checks on the accuracy of the data extracted were undertaken by a third author. Data were then analysed by the third researcher with descriptive statistics such as frequencies, percentages and measures of central tendency being ascertained.
643
Table 3 Details of unsuccessful completions. Topic Unsuccessful completion rates Length of time the unsuccessful stayed
Reasons given for unsuccessful completion
Category
1e3 months 4e12 months 13e24 months 25e36 months Over 37 months Failed preliminary examinations Domestic reasons Ill-Health Couldn't cope with the theory, transferred to SEN course Failed State final examinations Did not like nursing/could not cope with the reality of nursing Unsuitable for nursing Left to get married Not known (didn't return to duty) Pregnancy Transferred to another hospital to continue training Emigrated Missing data
Frequency
Percentage
198
30.9%
63 47 45 25 18 52
31.3% 23.95 22.9% 12.9% 8.9% 26.2%
21 21 19
10.6% 10.6% 9.5%
18 16
9.1% 8.1%
14 10 6
7.1% 5.1% 3.0%
2 2
1.0% 1.0%
1 16
0.5% 9%
Results
Ethical considerations The records analysed are now housed at the Liverpool Records Office. Previously they had been stored at the University where the original nurse training school had been sited. Permission to undertake the study was obtained from the University ethics committee. The hospital the training records pertained to has now closed and its facilities had been transferred to one of the North West's of England's large acute NHS Trusts. The data protection officer at this Trust was also contacted and gave permission for the analysis to proceed. Other ethical considerations related to the sensitivity of the information recorded in the records. It is thought that many of the individuals whose details were recorded could still be alive although in their 60s, 70s or even 80s. Most would be retired although a few could still be working. Ethical advice was given that caution about confidentiality and anonymity issues was needed. Therefore data extracted was assigned a case number so that the identities of the individuals were protected. Such things as secure storage of the files was ensured and password protected computers were also used.
As previously related there were 641 individual student nurse training records available for analysis. Years when the individuals entered their nurse training programme dated from 1955 to 1968 with over 46% (n ¼ 299) of the records relating to the 1961e1965 period. Nearly 92% of the recruits (n ¼ 688) were females with slightly over 8% (n ¼ 53) being male. Over 77% (n ¼ 497) were under 21 years old with less than 1% (n ¼ 4) being over 40 years old. The vast majority were unmarried (n ¼ 603). The greater part (n ¼ 371) had overseas addresses with almost 55% (n ¼ 350) originating from Southern Ireland. Local recruitment from the Liverpool area represented only 36% (n ¼ 232) of the total sample group. Table 1 gives further details of these findings. The records also gave the previous occupation of the recruits although it was found that there was a substantial proportion of missing data. That is 277 of the records did not note the recruits'
Table 4 Details of successful completions. Topic
Table 2 Previous occupation (n ¼ 641). Category
Frequency
Percentage
Nursing-type occupation Clerical Cadet nurse Student nurse at another hospital School Shop assistant Domestic work Manual work Factory work Teaching Nun Missing data
88 72 48 34 36 29 29 12 11 3 2 277
13.7% 11.2% 7.4% 5.3% 5.6% 4.5% 4.5% 1.8% 1.7% 0.4% 0.3%
Successful completion rates Intentions
Missing data
Category
Midwifery training Staff nurse post Marriage Returned to mental health nursing Undertake a further nurse training programme Emigrated Left nursing due to illness/domestic problems Not offered a post Left nursing for another occupation
Frequency
Percentage
443
69.1%
183 153 18 11
41.3% 34.5% 4.1% 2.5%
10
2.2%
6 5
1.4% 1.1%
3 2
0.7% 0.5%
52
11.7%
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previous occupation. Where the recruits' previous occupation was documented it was found that the majority (n ¼ 88) had a nursingtype background. Included were backgrounds in mental health, ‘chronic’, orthopaedic and fever nursing as well as those who had previously been enrolled nurses and auxiliary nurses. Others had been cadet nurses at the hospital the records pertained to (n ¼ 48). Some were also recorded as previously being a student nurse who had started their training elsewhere (n ¼ 34). Clerical (n ¼ 72), shop (n ¼ 29) and domestic work (n ¼ 29) dominated the non-nursing type occupational groups. Only a small number (n ¼ 36) were recorded as being at school prior to their recruitment. Table 2 gives further details of these findings. It was found that over 69% (n ¼ 443) of the student nurses had successfully completed their training. There was a sizeable amount of missing data (n ¼ 52) concerning what the intentions of the successful completers were. However, the majority were reported as intending to undertake their midwifery training (n ¼ 183), take up a staff nurse post (n ¼ 153), return to mental health nursing (n ¼ 11) or undertake some other form of further nurse training. Examples here included further training in tropical, theatre, intensive care and casualty nursing. A small proportion were documented as going to leave nursing altogether to get married (n ¼ 18), or that they were leaving due to domestic problems (n ¼ 5) or to take up another occupation (n ¼ 2). For example, one of the very few male nurses who completed their training was said to want to return to their previous job as a builder as the pay was substantially better, whereas another female nurse was leaving nursing to be a nun. A tiny amount (n ¼ 3) were said not to have been offered a post and had been asked to leave despite successfully completing their programme. Table 4 gives further details of the first employment of those who successfully completed their training. Concerning details of attrition from the training school it was found that over 30% (n ¼ 198) did not complete their training with the majority leaving within the first three months (n ¼ 63) of the programme. However, some (n ¼ 18) were found to continue with their training for over 37 months before leaving. Four people were recorded as leaving at 49e60 months after repeated failed attempts at their state final examinations. The main reasons given for unsuccessful completion were because the student nurses failed their preliminary training school/preliminary examinations (n ¼ 52). Domestic reasons (n ¼ 21) and ill-health (n ¼ 21) were also relatively frequently cited reasons. Examples here included students who returned home to Ireland to look after sick relatives or some who had suffered severe home-sickness. A number were reported as not being able to cope with theory and had been transferred to an enrolled nurse (EN) training programme (n ¼ 19). Several were said not to like nursing (n ¼ 16) or that they were unsuitable for nursing (n ¼ 14). Unsuitability was often couched in terms of the student being ‘useless’, ‘poor practically’ ‘lazy and indifferent to the needs of patients’ ‘selfish and irresponsible’ or ‘rude with little respect for senior staff’. Finally a few left to get married (n ¼ 10) or because they were pregnant (n ¼ 2). For example, one person was said to find ‘marriage more attractive option than nurse training’. Table 3 gives further details of these findings. Discussion Limitations of this study include such things as the relatively small number of the nurse training records analysed. The local nature of the material is a further limitation. However, the study does help to illuminate and put into context some present day dilemmas surrounding the recruitment and retention of nurses. Using a historical lens there are a number of lessons that nurse educators today can learn from the findings of the study conducted.
These are more fully discussed in the following sections of this paper. As related earlier recruitment and retention of nurses in the 1950s and 1960s was of national concern in the UK. Recruitment of student nurses was often poor. As a result in the 1950s there was a deliberate policy to attract qualified nurses and student nurses from the former British colonies and particularly the West Indies (Kramer, 2006). This is not reflected in data analysis undertaken as it was found only just over 1% of the student nurses had a Caribbean home address. However, it might explain why there was seemly poor local recruitment with only just only 36% of the records noting a local Liverpool address. It may also explain why over half the sample was recruited from Southern Ireland although as Yeates (2009) relates there may be other reasons in play. For example, nurses of this generation enjoyed high social esteem in Ireland with nursing as a profession being associated with middle-class status. As a result there was a considerable flow of Irish student nurses to England demonstrated in that 95% of the Irish Registered nurses in 1951 had trained in the UK (Yeates, 2009). Britain was a popular destination for training due to free right of access, cultural and linguistic similarities, available employment and frequent and inexpensive transport links. The downside was as Baly (1980) describes was that although immigrants were helping to keep the British health services afloat it was unlikely that all would be a permanent addition to the workforce. Thus immigrant recruitment was likely to perpetuate cycles of shortage of trained nurses. A situation Baly (1980) relates as being unhelpful to the immigrant staff as it was to the hospital authorities of the period. Similarly in more recent times a shortage of trained nurses in the UK has resulted in employment of immigrant staff to cover the shortfall. For example, Donnelly (2013) identifies that the numbers of foreign nurses coming to Britain to work has doubled over recent years. NHS hospitals are also thought by Donnelly to be ‘poaching’ nurses from countries who can ill afford to lose their trained staff as they have major health issues of their own. In the UK shortages of trained nurses can often be traced to national and local inadequacies in commissioning of student nurse education numbers. The resultant cycle of glut and lean years of numbers of trained nurses available for employment seems to be a situation that is never dealt with satisfactorily and lessons from the past have not been acted upon (Taylor et al., 2010). Analysis of the training records also shows that the personal characteristics of the student nurses the records pertain to is not dissimilar to what is reported in the literature relating to the time. Kirby (2009) for example, in an analysis of archival and oral sources relating to training in the 1940s indicates that the majority of recruits at the time were young, unmarried, women for whom hospitals took on a ‘loco parentis’ role. The main incumbent of this role were hospital matrons. The restrictions imposed on the student nurses related to how seriously this responsibility was viewed by many matrons. As described earlier a student nurse's life was often governed by petty regulations imposed both on the wards and also during off-duty leisure time. That nurse training in the 1950/60s was paternalistic and anachronistic and in being so failed to reflect trends in the wider society which were directed at increasing civil rights, feminism and liberalism. The recruitment profile of student nurses usually being young single women largely continued to be the case in the 1950s and 1960 (Singh and Smith, 1975). However, by the 1970s and 1980s there was increasing concern that the rapidly changing demography of the UK would result in a depleted pool of potential young recruits. Indeed Houltram (1996) reports integral to the introduction of Project 2000 in the 1980s and 1990s was a desire to widen
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access to nurse education so as to include greater proportions of males and mature students in the student body. Prior to this time the incidence of male nurse recruits was usually small in number, apart from in specialities such as mental health nursing. This is again is reflected in findings of the analysis with less than 8% of the records relating to male student nurses. It is also borne out by the more general position of male nurses. For example, it was not until 1960 that the Royal College of Nursing (RCN) in the UK changed its charter and admitted men (Whittock and Leonard, 2003). Societal taboos in many of the developed nations were also slow to change and it was not until later decades that nursing became less related with ‘women's work’ and associated negative gender stereotypes (Jinks and Bradley, 2003). (The term developed nations meant to imply a country that has a highly developed economy and advanced technological infrastructure relative to other less developed nations.) Similarly mature students and particularly older married women were not actively recruited as student nurses. Whilst marriage and nursing were not very compatible as it was a requirement for students to live-in the nurses' home it was however, also in line with the social norms of the time when married women's primary roles were seen as being homemakers and child rearers (Tilly and Scott, 1987). Failure of many of the records to give the previous occupation of the recruits is thought probably due to the fact that most did not have a previous occupation as they were an age when they were likely to be still at school. Being at school was likely not to be classified as a previous occupation by the record keepers. However, where previous employment details were given the propensity for the recruits to have some nursing-type experience is very similar to what forms of part of recruitment criteria deployed today by many nurse education institutions. For example, in more recent times in the UK interviews remain an important part of nurse education recruitment strategies with recruits needing to show that they have some insight into the realities of nursing as a profession (Karstadt, 2011). The importance of this is underlined in the present analysis in that successfully completing the programme was significantly related to those who had previous nursing type employment. Nursing as stressful and demanding is well-reported with authors such as Glossop (2001) relating the difficulties many students have coping with clinical practice and the impact this has on today's student nurse attrition rates. This is an issue that is not solely UK related with authors from many other countries reporting similar concerns (Clark and Springer, 2007; Elliot, 2002; Ralph et al., 2009). The nearly 31% attrition rate identified from analysis of the training records was by no means unusual at the time. For example, Baly (1980) reports a national average of 39% attrition from nurse training in 1961 with some hospitals having attrition rates of well over 50%. In more recent times attrition rates from pre-registration nurse education are generally less. For example, Andrews et al. (2005) in a comparative study involving two UK universities found attrition rates from 1997 to 2000 was 17.7%, whereas Mulholland et al. (2008) in a longitudinal cohort study identifies an attrition rate of 22% and Kevern et al. (1999) identifies a 25% attrition rate in their study. Nevertheless some international studies suggest that the UK may still have comparably high attrition rates. For example, in Australia an investigation which began in 1999 found attrition from nurse education programmes to be only 7% (The National Nursing and Nurse Education Taskforce, 2005). These and similar findings need, however to be viewed with caution as accurate calculation of nurse education attrition rates is reported by a number of authors to be notoriously difficult. For example, Glossop (2001) highlights the complex methodological issues involved in measuring nursing student attrition rate with use of a comparable format and an agreed definition of attrition being
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problematic. Such things as databases not tracking individuals who change courses, or who had deferred their studies or changed to part time modes of study are some of the difficulties identified by Glossop (2001). A natural progression from consideration of nurse education attrition rates leads to exploration of why some leave without successfully completing their studies. Analysis of the training records shows academic failure to be the primary reason why many did not complete their training. Whilst a number of training records analysed describe student nurses as being ‘dull’ or ‘not scholarly up to SRN training’ they give no indication of their academic backgrounds prior to recruitment. However, for those with a nonnursing type occupational background most had jobs that at the time only needed modest educational qualifications, if any at all. For example, analysis of the training records show only one person gave teaching as their previous occupation whereas the majority were engaged in factory, shop, clerical or manual work. The Platt Report (RCN, 1964) sets out what many of the time considered the heart of the problem and was likely to be the case in the training records analysed. ‘All those who wish to nurse and who were prepared to be persistent in seeking admission to general training were likely to be accepted, if not for the hospital of their first choice then in some other hospital which was short of staff’ (p6, para 17). The Platt Report (RCN, 1964) recommended that the standard entry to nurse training should be five subjects at General Certificate of Secondary Education (GCE) level (Ousey, 2011). (The GCE was first introduced in England and Wales in 1951 as a type of school leaving certificate in a variety of subjects. It had examinations graded into ordinary levels, ‘O-Levels’, for the top 25% and (from 1965) Certificate of Secondary Education (CSE) for lower attaining pupils.) However, as White (1985) relates when the minimum education level for entrants to nurse training was reinstituted in 1962 the entry level was set at two GCEs and remained so after the findings of the Platt report were published. Nevertheless, the General Nursing Council (GNC) continued to express the opinion that lack of standard entry criteria in many UK hospitals was the paramount cause of high attrition (MacGuire, 1969) and as a consequence student nurses studying at the time often could not cope with the requirements of the nursing syllabus. This is borne out in the present analysis where it was found that some left in the first months of their training due to failing their preliminary examinations. Indeed the analysis revealed a surprising number of students continued with their training for as long as four and five years only to eventually leave after failing their state finals examinations after repeated attempts. Clearly the level of nurse education today is higher than that of the time of the training records with graduate entry to the profession being the norm for many nations. (Graduate entry means completion of an undergraduate programme prior to nurse registration.) This has certainly through time given rise to re-evaluation of academic entry criteria in many countries. For example, in the UK whilst there are no national minimum entry requirements for pre-registration nurse education candidates must be able to demonstrate evidence of literacy and numeracy skills (Nursing and Midwifery Council (NMC) 2004). Nevertheless most UK universities that offer nurse education programme set their entry criteria at a minimum of five GCSEs and ‘A’ level study or equivalent for entry to undergraduate programmes being customary. (A-levels studies normally follow on after GCE examinations and are pre-university examinations in three or four subject areas studied over a two-year period.) This level of education attainment is similar to many other countries. For example, in the United States (US) whilst it retains multiple entry levels to nurse education programmes, many programmes
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are at undergraduate or masters level and have entry criteria similar to those of other US university programmes (Workforce and Training Taskforce, 2007). Despite raising academic entry criteria for nurse education in the UK it is disheartening to relate that a number of authors report attrition due to academic failure continues to be one of the main reasons why students leave without completing their programme of study (Glossop, 2001). Some also identify that younger students with only modest academic achievement are at most risk of unsuccessful completion (Buchan and Semour, 2004), a profile not dissimilar to those that many of the nurse records pertain to. It would seem that some of the issues of yesterday continue to remain problematic today and leads to recommendations that careful monitoring is needed of the progress of those with only modest educational attainments. Likewise that substantial number of entrants whose records were analysed left due to domestic and ill health problems resonates with many of modern day studies. For example, Kevern and Webb (2004) investigated the needs of mature students and found whilst many seemed to be more motivated than younger students and appeared better able to study independently they did have specific problems which may need addressing. These are related to various issues amongst which may be finance problems and family commitments. Recommendations that arise out of these findings relate to having in place robust student support systems and counselling services. The final area of the nurse training records analysis concerns the first destination of those who successfully completed their programme. It was shown that most stayed at the hospital where they had trained with the majority being appointed to staff nurse posts or going on to undertake their midwifery training. A national shortage of nurses in the UK in the 1960s meant there was little fear of not being able to get a post (Kirby, 2009). This contrasts vividly to the position that many newly qualified nurses in the UK and other countries find themselves in today. For example, in recent years uncertain economic times and reductions in the demand for nurses by the NHS which is the main employer of nurses in the UK has meant there has generally been a reduction in the numbers of registered nurses over the last few years. As Buchan and Semour (2010) report from the findings of a UK nursing labour force review there are of signs of redundancies and recruitment freezes emerging in some parts of the NHS, particularly in England. These dilemmas are not confined in the UK as many countries are facing economic constraints which will no doubt prove to result in recruitment and retention difficulties both for the profession and many newly qualified nurses. Conclusions It is concluded that the findings of this study serve as a reminder of how historical analysis can illuminate and put into context present day dilemmas. It is perhaps salutary to note that many of the recruitment and retention issues facing the nursing profession today are not new as many are similar to those reported in the 1950s and 1960s. For example, whilst recruitment of males, mature students and particularly older married women has improved over time there is still room to further increase their numbers and help solve some present day recruitment issues. Similarly whilst some improvements in retention have been achieved it is still unacceptability high when UK rates are likened to other countries. Unsuccessful completion due to academic failure is an area that remains problematic and needs further deliberation. Whilst attrition in the UK is obviously a concern to both universities and NHS manpower planners it should not be overlooked that unsuccessful completion also comes with a personal cost. Whilst there will
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