42 june 2 :: vol 24 no 39 :: 2010 NURSING STANDARD

FOLLOWING THE REVIEWof pre-registration

nurse education in the UK, the Nursing and
Midwifery Council (NMC) (2009) confirmed that
all pre-registration nursing programmes will be
provided at graduate-only level from 2010.
Graduate-only programmes may be viewed
as a way to integrate nurse education into higher
education (Burke and Harris 2000). These
programmes may also help to address the negative
view of nursing and its lack of equal status within
higher education (Sellers and Deans 1999,
Miers 2002). Ultimately, the introduction of
graduate-only programmes may help to ensure
that nursing achieves a similar status to other
professions (Hancock 1997).
The implementation of graduate programmes
will ensure that nurses are knowledgeable,
competent and better equipped to address future
public health challenges (Davies 2008). It has
been suggested that the introduction of these
programmes will improve the efficiency of
clinical nurses who will be more confident
in using research to help deliver evidence-based
care (Newton 1997). Effective care will
ultimately help to reduce patient mortality
(Tourangeau et al 2006).
Purchasers of nurse education suggest that
graduate nurses are more likely to meet the
requirements of future healthcare organisations
because of their enhanced expertise and skills
(Burke and Harris 2000). Tourangeau et al (2006)
also identified that graduate nurses will be less
likely to leave the profession after registration.
The perceived benefits of graduate-only
programmes have been challenged. Ward (2002)
questioned the proposed relationship between
graduate nurses and improvements in patient
care, suggesting that the added academic content
of current pre-registration nursing programmes
has not resulted in significant improvements.
Kyrkjeb and Hage (2005) claimed that nursing
education does not occur in a vacuum and that
a hidden curriculum plays an important part
in shaping students values, attitudes and
behaviours. It is suggested that nursing
students are sometimes exposed to clinical
learning situations of mixed quality and that
improvements in patient care will be achieved
only with significant cultural change throughout
the total educational system (Institute of
Medicine of the National Academies 2003,
Kyrkjeb and Hage 2005).
Recruitment
While there may be disagreement about the
potential advantages and disadvantages of
graduate-only pre-registration nursing
programmes, the initiative may create additional
recruitment and retention problems for
employers and providers of mental health
nurse education.
Historically, nursing has tended to recruit
entrants from a narrowly delineated population
mainly students who have failed to achieve the
necessary qualifications for entry to preferred
education programmes or careers (Buchan 2003).
Entry to nursing provides individuals with the
potential to achieve increased social mobility
Graduate-only pre-registration
mental health nursing programmes
ODonnell H (2010) Graduate-only pre-registration mental health nursing programmes.
Nursing Standard. 24, 39, 42-46. Date of acceptance: March 12 2010.
&
art &science mental health
Summary
This article examines the perceived benefits of graduate-only
pre-registration programmes in mental health nursing, and the potential
social aspiration and attrition problems that may result. A number of
strategies are identified to assist student integration into higher
education and minimise any increase in attrition rates.
Author
Hugh ODonnell, nurse lecturer, school of nursing and midwifery,
Queens University, Belfast. Email: h.odonnell@qub.ac.uk
Keywords
Academic qualifications, education, mental health,
nursing careers
These keywords are based on subject headings from the British
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.
p42-46 w39 Q8_A&S 28/05/2010 11:27 Page 42
by attaining added social respectability and
enhanced personal aspirations. Those engaged
in directing reform in nurse education should
consider the effects of any proposed policy change
on social mobility and gender equality (DAntonio
2004). It is not known, as yet, how the introduction
of graduate-only pre-registration programmes will
affect social mobility. However, it is possible that
some individuals and sections of society who have
already experienced inequality, for example
mature entrants who previously had the
opportunity to enter higher education with GCSE
(general certificate of secondary education)
qualifications, may become increasingly excluded
from participation in nurse education. It is
important that nursing retains its capacity
to provide added social aspirations within
a professional paradigm (Nelson 2002).
Mental health nursing has found it difficult
to attract new students. While other nursing
specialties have tended to recruit young female
school leavers, mental health nursing has used
open access routes to recruit a broader range of
potential students, including entrants who tend
to have more modest educational qualifications
(Buchan 2003). It is unclear whether the academic
and age profile of new entrants to mental health
nursing will alter following the introduction of
graduate-only programmes. However, recruitment
to mental health nursing may remain difficult
because of the negative attitudes that many
potential students have towards it and its services
(Stevens and Dulhunty 1997, Happell 2001,
Davidson and Connery 2003).
A potential future recruitment crisis in
mental health nursing may be avoided by
increasing the number of assistant practitioners
recruited to support nurses. It has been
suggested that the introduction of skill mix
initiatives will eventually lead to improvements
in organisational effectiveness and the quality
of patient care (Buchan and Dal Poz 2002).
Having greater numbers of assistant
practitioners may mean that some activities
that nurses carry out can be delegated, which
will allow the nurses to engage in more complex
care interventions.
The recruitment of assistant practitioners
to undertake roles that were previously the
reserve of mental health nurses is not
universally supported. Some believe that
their introduction will eventually threaten the
future of mental health nursing and that this
initiative is motivated by economic factors
rather than patient-centred care (Warne and
McAndrew 2004). McKenna et al (2004)
suggested that it will blur professional roles,
and that these practitioners may be delegated
duties that exceed their individual competencies
and capabilities.
It is worth noting that while arguments used
to support graduate-only nursing programmes
frequently refer to its positive effects on patient
care, concerns are also expressed about the
effects that assistant or associate practitioners
will have on patient care (Brannon 1990,
Zimmermann 1995).
Attrition
One estimate of student attrition rates suggests
that 25% of nursing students leave
pre-registration nursing programmes before
completion (Buchan 2006). Attrition also appears
to be higher in nursing students than in other
higher education student populations (House of
Commons Committee of Public Accounts 2008).
Scotland is reported to have the highest rate of
nursing student attrition in the UK. This is
thought to be a direct result of the decision
to increase the number of non-traditional
students, for example those who have not
achieved A level qualifications, entering the
profession at a time when insufficient systems and
resources were in place to support this student
population (Waters 2006).
Because of the recruitment difficulties, mental
health nursing programmes have tended to recruit
a disproportionate number of non-traditional
students those who have not previously
achieved A level qualifications. This trend has
continued following the integration of nursing
into higher education, even though evidence
suggests that students with less impressive
academic profiles are at heightened risk of
academic difficulties and subsequent attrition
(Yorke 1997, Leathwood and OConnell 2003,
Lawrence 2005, Smith 2007).
The development of foundation degrees is one
way to address the academic profile deficits of
some students who enter mental health nursing.
Foundation degrees are aimed at assisting
non-traditional students to develop the skills
and capabilities necessary to adjust to higher
education study. Foundation degrees are a mix
of academic and vocational study. The profile of
students who have commenced these degrees is
reported to be broadly consistent with students
who previously completed the Higher National
Diploma programmes that permitted entry into
higher education (Quality Assurance Agency
for Higher Education 2005). Students without
traditional entry qualifications may complete
foundation degrees and gain accreditation of
previous learning achievements. This allows
them to progress to professional courses
within higher education, such as nursing
(Webb et al 2006).
Foundation degrees are often called
short-cycle or intermediate degrees, and it is
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p42-46 w39 Q8_A&S 28/05/2010 11:27 Page 43
believed their introduction will help address the
academic drift towards an elitist model that some
observers claim dominates higher education
(Parry 2005). Foundation degrees are flexible
in design and structure and offer practical
benefits to employers in that they expose future
staff to the realities of study and the work
environment. The development of foundation
degrees has a number of potential advantages
for higher education organisations, especially
as they aim to increase student participation
at a time when competition between providers
is increasing.
There are, however, those who are critical of
foundation degrees. Gibbs (2002) questioned the
use of the word degree for this largely vocational
programme of study and suggests it serves to
create an illusionary parity of status with students
undertaking other undergraduate courses. Webb
et al (2006) said that whether their introduction
will democratise higher education, or merely
differentiate further between students and
courses, remains unclear. They suggested that the
value of foundation degree courses, and their
potential parity with other qualifications, can
be determined only following rigorous empirical
investigation (Webb et al 2006).
A multitude of potential problems could arise
if student attrition from mental health nursing
courses persists or increases after the introduction
of graduate-only pre-registration nursing
programmes. Nursing students who withdraw
will experience feelings of disappointment and
personal distress (ODonnell 2009), and other
students may experience feelings of vulnerability
and demoralisation (Lloyd 2008). Nurse teachers
may experience guilt and feelings of failure when
students decide to leave (Symanski 1991).
A decline in the future mental health nursing
population because of student attrition may have
a negative effect on the services future capacity
to meet the populations needs.
Increased student attrition rates from
pre-registration programmes may have negative
effects on providers of mental health nurse
education. The financial cost of an increase in
attrition can be significant. It may include factors
such as lost bursary effects, additional costs
associated with educating replacement nurses,
and indirect costs such as time lost by nurse
teachers and mentors as a result of students who
subsequently leave the programme.
Future contracting and funding arrangements
are calculated by the number of nursing students
who complete pre-registration nursing courses.
Increased attrition from mental health nursing
courses may be interpreted as an indicator of
programme weakness or a reflection of poor
student support (Johnes and McNabb 2004).
Schools of nursing with low student progression
rates may find it more difficult to recruit mental
health nursing students in the future because
of a negative public image (Lipley 2000),
and commissioners of nurse education may
turn to alternatives if providers demonstrate
high student attrition rates. This would have
a significant effect on those providing mental
health nurse education and potentially threaten
the tenure of those engaged in this area
of education.
Future of mental health nursing
Those responsible for mental health nurse
education should anticipate and plan for
increased attrition following the introduction of
graduate-only pre-registration programmes, and
recognise the need for a co-ordinated and
systematic response to help minimise this risk.
Strategies that might help to resolve nursing
student attrition are outlined in Table 1.
Higher education providers of mental health
nurse education should develop more effective
relationships with feeder providers to ensure that
future students have the necessary skills and
capabilities to adjust and cope with degree-level
study. Pre-university study programmes
permitting entry to pre-registration courses
should provide a cultural context that equips
students with the independent study skills
necessary for successful academic adjustment
within higher education. Nurse education
providers should also assemble more
comprehensive information on students at
the point of entry to help accurately determine
the academic and other needs that individuals
may require to progress and successfully
complete graduate-only pre-registration
mental health nursing programmes.
Education providers should have a clear
understanding of students expectations.
Unrealistic expectations have been blamed for
heightened student stress, academic adjustment
problems and attrition (Howard 2001, Last
and Fulbrook 2003, Knox 2005, Jeffreys 2007,
Smith 2007). Realistic expectations of
graduate-only mental health nursing
programmes may be achieved through effective
career advice, availability of more accurate
course content information, and effective
selection procedures. The selection process
should test the accuracy of students
expectations of the content and academic
challenges of graduate-only programmes.
There is evidence to suggest that transition
programmes containing study advice,
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academic support systems, tutoring
arrangements and the availability of other
learning assistance may assist integration into
higher education and reduce attrition rates
(Colton et al 1999, Schnell and Doetkott 2003,
Braxton et al 2004). The introduction of peer
mentoring may also have a positive effect
on the levels of social involvement and
academic self-confidence of future mental
health nursing students. Effective peer
mentoring arrangements may result in
meaningful student engagement and help
achieve positive commitment (Mangold et al
2003, Padgett and Reid 2003).
Following the introduction of graduate-only
pre-registration nursing programmes,
attendance and progression should be
monitored closely, as non-attendance is
common among nursing students performing
less well academically (Jeffreys 2007,
McCarey et al 2007). Students may employ
non-attendance strategies to suppress the stress
associated with academic difficulty (Jones and
Johnston 1997). Those engaged in mental
health nurse education should provide
appropriate support to students experiencing
academic-related stress. It is also important that
education providers recognise the costs and
june 2 :: vol 24 no 39 :: 2010 45 NURSING STANDARD
Strategies to resolve nursing student attrition
TABLE 1
Strategy Action
Develop effective Ensure that further education programmes
relationships with and other relevant pre-university feeder
organisations programmes adequately prepare future
students for graduate-only study.
Assess student Identify whether students have realistic
expectations expectations of graduate-only courses and
their academic demands.
Provide nursing students Ensure students have access to comprehensive
with higher education information regarding graduate-only programmes
information and their academic demands to ensure they
are adequately prepared.
Provide higher education Help prepare future students by giving them the
transition courses skills and capabilities necessary to cope with
the transition to higher education.
Provide student support Ensure that academic and/or pastoral support
is in place, as well as effective peer mentoring
and personal tutor arrangements.
Promote wider student Provide access to taster experiences.
participation
Measure student Monitor student progress to help detect
progression disengagement or stress. Provide access
to further support if required.
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