ARTICLE IN PRESS

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International Journal of Nursing Studies 45 (2008) 1310–1318

www.elsevier.com/ijns

Calculating the costs of work-based training:The case of NHS Cadet Schemes

Ian Normana,�, Charles Normandb, Roger Watsonc,Jan Draperd, Sandra Jowette, Samantha Costera

aFlorence Nightingale School of Nursing & Midwifery, James Clerk Maxwell Building, King’s College London,

Waterloo Road, London SE1 8WA, UKbHealth Policy and Management, Trinity College Dublin, Ireland

cUniversity of Sheffield, UKdOpen University, UK

eInstitute for Health Services Research, University of Luton, UK

Received 23 September 2005; received in revised form 27 September 2007; accepted 2 October 2007

Abstract

Background: The worldwide shortage of registered nurses [Buchan, J., Calman, L., 2004. The Global Shortage of

Registered Nurses: An Overview of Issues And Actions. International Council of Nurses, Geneva] points to the need for

initiatives which increase access to the profession, in particular, to those sections of the population who traditionally do

not enter nursing. This paper reports findings on the costs associated with one such initiative, the British National

Health Service (NHS) Cadet Scheme, designed to provide a mechanism for entry into nurse training for young people

without conventional academic qualifications. The paper illustrates an approach to costing work-based learning

interventions which offsets the value attributed to trainees’ work against their training costs.

Objective: To provide a preliminary evaluation of the cost of the NHS Cadet Scheme initiative.

Data source: Questionnaire survey of the leaders of all cadet schemes in England (n ¼ 62, 100% response) in December

2002 to collect financial information and data on progression of cadets through the scheme, and a follow-up

questionnaire survey of the same scheme leaders to improve the quality of information, which was completed in January

2004 (n ¼ 56, 59% response).

Principal findings: The mean cost of producing a cadet to progress successfully through the scheme and onto a pre-

registration nursing programme depends substantially on the value of their contribution to healthcare work during

training and the progression rate of students through the scheme. The findings from this evaluation suggest that these

factors varied very widely across the 62 schemes. Established schemes have, on average, lower attrition and higher

progression rates than more recently established schemes. Using these rates, we estimate that on maturity, a cadet

scheme will progress approximately 60% of students into pre-registration nurse training.

Conclusions: As comparative information was not available from similar initiatives that provide access to nurse

training, it was not possible to calculate the cost effectiveness of NHS Cadet Schemes. However, this study does show

that those cadet schemes which have the potential to offer better value for money, are those where the progression rates

e front matter r 2007 Elsevier Ltd. All rights reserved.

urstu.2007.10.004

ing author.

ess: ian.j.norman@kcl.ac.uk (I. Norman).

ARTICLE IN PRESSI. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–1318 1311

are good and where the practical training of cadets is organised such that cadets meet the needs of patients which might

otherwise have to be met by non-professionally qualified staff.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Evaluation research; Cost; Nurse education; Workforce issues

What is already known about the topic?

�

Cadet schemes, abandoned in the 1970s, have been

re-introduced in the United Kingdom as a mechan-

ism for increasing recruitment into nurse training.

�

National Health Service (NHS) Cadet Schemes have

been successful in widening entry to professional

healthcare study to young people without conven-

tional academic qualifications, and a recent evalua-

tion has shown that they also recruit a higher

proportion of students from Black and minority

ethnic groups than a comparator group of pre-

registration programmes.

�

There have been no national economic evaluations of

cadet schemes and so whether they represent good

value for money is unknown.

What this paper adds

�

The paper demonstrates an approach to costing

work-based learning training interventions which

offsets the value of work carried out by trainees

against training costs.

�

The mean cost of producing a cadet who progresses

successfully through a cadet scheme and into a pre-

registration nursing programme varies widely across

existing schemes.

�

It is estimated that established cadet schemes have

the capacity to progress around 60% of cadets into

nurse training.

�

The financial impact of offsetting the value of work

of students on clinical placement against the costs of

training initiatives is substantial.

�

Cadet schemes have the potential to offer good value

for money if progression rates are good and the

practical training of students is organised such that

cadets meet the needs of patients which might

otherwise have to be met by other staff.

1. Background

The UK Government has made a commitment to

introduce more flexible pathways into and through

nurse education, thereby encouraging wider recruitment

into the profession from groups including those under-

represented in the NHS, for example, Black and

minority ethnic groups (DH, 1999). There has been a

recent drive by the Government to promote the

development of schemes to improve and extend access

to pre-registration education and training (DH, 1999;

UKCC, 1999) in nursing and allied health professions

and to retain the existing healthcare workforce

(DH, 2000). The NHS Education Consortia, and later

the Workforce Development Confederations (WDCs),

were required to ‘facilitate the development and

potential expansion of such schemes’ (HSC 1999/

219:10). This paper reports on the introduction of one

of these developments, the ‘NHS Cadet Scheme.’

Currently in the UK, students qualify as healthcare

professionals by undertaking pre-registration training

which culminates in either a diploma or degree

qualification. There are many different routes into pre-

registration nursing education. Traditional routes are

regarded as the standard minimum academic entry

qualifications which are normally GCSEs and or/A’

levels. For students who do not possess these qualifica-

tions there is a diverse range of alternative ‘access’

courses. Normally, these access courses are run within

the college or university sector, and include courses such

as GNVQ (General National Vocational Qualification)

and BTEC (Business and Technology Education Coun-

cil) National Diploma in Health Studies. Such courses

normally attract younger students in the 16–18 year old

age band and usually consist of 2 years of study. These

types of access courses are classroom based and are

designed to enable students to achieve an acceptable

academic standard to enter pre-registration education.

NHS Cadet Schemes are training initiatives, locally

developed in response to workforce issues, which also

prepare participants for pre-registration training. Due to

development at a local level, there is no standard

minimum entry requirement for cadet schemes, with

some requiring a minimum number of GCSEs or

equivalent qualifications and others having no specific

entry requirements. Schemes are established in partner-

ship with NHS organisations and higher education

colleges and also tend to be 2 years in duration. In the

sense that cadet schemes offer a route into nursing and

Allied Health Professional pre-registration education,

they are examples of access programmes. Cadet schemes

also offer the chance to obtain an academic qualification

(e.g. NVQ) for entry into pre-registration training.

However, the key difference between cadet schemes

and other types of access course is the combination of

ARTICLE IN PRESSI. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–13181312

both academic preparation and clinical experience that

the schemes provide. Cadet schemes have a strong

practice focus, with a range of placements organised for

students within the host organisation. Whilst working in

this practice environment, cadets are expected to achieve

a range of vocational competencies, which are assessed

by qualified assessors. In addition, unlike students

leaving other access courses, cadets who successfully

complete their cadetship will normally have some form

of preferential treatment in the process of gaining a

place on a pre-registration programme.

1.1. Previous studies of cadet schemes

Cadet entry to nursing is not a new concept in the

United Kingdom (UK). From the 1950s–1970s cadet

courses were common in the UK, often managed locally

by hospital management committees with no official

approval or monitoring from a national body (Hulme,

1989). However, despite the apparent success of these

schemes, during the late 1970s they were discontinued

and little evaluative literature about them is available.

The ‘modern’ cadet schemes began in the 1990s, with

the introduction of the first scheme in 1997 (Culley and

Genders, 2003). In June 2002, there were 62 NHS Cadet

Schemes running in England. Information from the

Department of Health (DH) for England, suggests that

there are now over 80 schemes and that the Government

is committed to further expansion. The DH allocated a

further £15 million in 2003, via the WDCs, to maintain

existing schemes and provide support to establish new

schemes over the next couple of years.

Despite the proliferation of NHS Cadet Schemes,

there are few published papers on the topic. Previous

evaluations have focused on local schemes (Clifford and

Wildman, 1999; Clifford et al., 2000; Draper and

Watson, 2002) and the relevance of findings from these

evaluations to cadet schemes generally is uncertain.

Taylor et al. (2001) provides some information on

existing cadet schemes across England. However, in

2002, when the present study was commissioned by the

DH, there had been no rigorous national evaluation. In

particular, it was not known whether NHS Cadet

Schemes were meeting their primary goals of: (a)

widening access to the healthcare workforce by attract-

ing those who might not otherwise have been recruited,

(b) progressing recruits successfully through the cadet

scheme and into pre-registration training programmes

and (c) achieving these objectives in a cost-effective way.

Cadet schemes offer a route into nurse education, in

particular, for those who do not hold sufficient entry

qualifications for direct entry. Evidence from this DH

evaluation suggests that cadet schemes are indeed

improving access to healthcare study to people from

Black and ethnic minority backgrounds. The extent to

which they widen access to professional healthcare

education has already been reported (Draper et al.,

2004; Watson et al., 2005). Access could potentially be

widened further if more cadet schemes were flexible in

their modes of delivery (e.g. more part-time courses,

more than one entry annually) and if all schemes

dropped any requirement for formal entry qualifica-

tions. However, the value of widening access to training

and reducing the social exclusion of those recruited to

cadet schemes are not incorporated within this cost

evaluation. In addition, there is a potential tension

between goal (a), which is to widen access, and goals (b)

and (c). Students who are recruited with few (or no)

formal qualifications may be less able to meet the

academic and practical requirements of a cadet scheme

and subsequent pre-registration education, and so may

not progress so successfully into the health professions.

Watson et al. (2005) recent review of the literature on

cadet schemes showed only the existence of UK

publications. Anecdotally, we are aware of cadet

schemes that existed in Australia; however, there

appears to be no published research on these schemes.

In light of this, a study of cadet schemes in the UK has

international relevance due to the worldwide shortage of

registered nurses (Buchan and Calman, 2004). While

cadet schemes are only one way of addressing this

shortage, they may have a part to play in countries other

than the UK, alongside other approaches to the global

shortage of nurses, such as retaining older workers in the

workforce (Watson et al. 2003).

2. Methods

2.1. Objectives of the evaluation

This paper reports on the extent to which cadet

schemes have been successful in guiding participants

through the cadet scheme and into pre-registration

training programmes and provides estimates of the costs

of the scheme.

2.2. Conceptual framework

To undertake a full cost effectiveness analysis (CEA),

it would be necessary to compare the costs of the cadet

scheme with those of other initiatives designed to

achieve a similar outcome, i.e. progressing students into

pre-registration nurse training. However, suitable com-

parative information on other schemes was unavailable

at the time of analysis and so a CEA was not feasible.

What is presented in this paper is a simple cost

description, conducted from the perspective of the NHS

and not any one particular organisation or group. The

cost of training an individual cadet will also be sensitive

to (a) the number of cadets who progress to professional

nurse education and (b) the value of the contribution of

cadets to healthcare work during training. Information

ARTICLE IN PRESSI. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–1318 1313

on (a) was collected by surveying cadet schemes with

regards to the entry, progression and attrition of students

on the schemes since 1999. This permitted a sensitivity

analysis to be conducted using models which estimate

costs based upon high and low projections of (a).

An important issue arises in training programmes

where trainees are learning in working settings. In this

case, the work carried out as part of the training includes

activity that might otherwise be done by health care

professionals or health care assistants. Although there is

considerable variation across schemes, the practical

contribution of cadets to healthcare work is potentially

substantial (Draper et al., 2004). In the following analysis,

the value of clinical work during cadet placement and

moreover the potential savings from it (b), were estimated

on the basis of the number of health care assistant hours

saved, and costed on the basis of mid-scale point health

care assistant salaries and other employment costs. This

data was then used to generate further models which

estimate the cost offset of this healthcare work per cadet.

Investing in professional skills is like any other

investment, in that the returns come as a flow of benefits

over time. In addition skills require maintenance and

continuing development. Therefore, for the cadet scheme

to be considered a successful initiative in the long term, it

would be important to ascertain; (1) how many cadet

students who progress to pre-registration nursing training

successfully complete their course; (2) how many ex-cadet

students enter the nursing workforce as qualified staff;

and (3) the average length of a career in nursing of those

who enter nurse training through a cadet scheme.

A comparison of these long-term outcomes across

different pathways into pre-registration training would

be invaluable. However, such estimations are difficult,

especially given the recency of the cadet schemes’

introduction. Although it was not possible to incorporate

these outcomes into this evaluation, it may be possible to

obtain such information in future research.

2.3. Samples, data collection procedures and response

rates

Data on progression, attrition and financial data were

gathered in two waves. Cost data were collected via the

questionnaire survey of all NHS Cadet Scheme leaders

(n ¼ 62, 100% response) which was carried out between

October and December 2002.

Financial information on costs of the schemes; it

requested information on the following areas:

�

cadet grants and other expenses;

�

operating, procurement;

�

marketing and overheads costs;

�

occupational health and liaison costs;

�

human resources (staff involved in teaching, mentor-

ing and assessing cadets);

�

staff training and assessor costs;

�

access to additional funding;

�

student work placements; and

�

costs to the students.

Respondents provided comprehensive responses to

questions concerning organisation, management and

characteristics of their scheme, but only partial data on

progression and attrition of cadets, and very limited

data on costs. In view of this, it was decided to re-survey

this sample of 62 Cadet Scheme Leaders, between April

2003 and January 2004, to collect more comprehensive

data. Some scheme leaders did not manage the budget

for their scheme and so were not in a position to provide

accurate financial data. In such cases a separate

questionnaire requesting the required information was

sent to the responsible finance director. Six of the 62

schemes had been discontinued since the first survey in

2002. Of the 56 schemes remaining, after three

reminders, 33 questionnaires (59%) were returned in

the second wave of data collection. The quality of

economic activity data returned was variable, but unit

cost data on major items of expenditure such as salaries

and bursaries was robust.

2.4. Ethical considerations

Multi-centre Research Ethics Committee approval

was obtained for the study. Confidentiality of schemes

and individual respondents was assured along with the

right to withdraw from the study at any time.

2.5. Data analysis

Financial data were entered into an SPSS database

(version 10.5) and subjected to descriptive statistical

analysis. Data from both surveys were drawn on to

calculate entry to cadet schemes. Progression rates were

aggregated across schemes and calculated for consecu-

tive intakes, in order to highlight variation in progres-

sion over time, for example, from the first intake on a

newly developed scheme, to the latest intake on a

‘mature’ scheme.

Costs were calculated by multiplying data on activity

using a vector of unit cost data for salaries and other

expenses. Since there is uncertainty about the value of

the work done by cadets during their workplace

training, three models are presented reflecting three

levels of net contribution.

3. Results

3.1. Costs of cadet schemes

Table 1 shows the elements of cost of the cadet

schemes in the study. Where unit cost information was

ARTICLE IN PRESS

Table 1

Cost per cadet (n ¼ 423) and for the schemes (n ¼ 33) overall

Mean per

cadet (£)

Total for

33 schemes (£)

Bursary/salary per cadet 5697 2911167

Scheme leader salaries 3892 1646329

Cost of staff time on mentorship 1297 548776

Staff training cost 943 399062

General administration 780 330099

Miscellaneous costs 587 248193

Cost of staff time on assessment 556 235190

Assessors’ training costs 469 198512

Travel (2nd year) 362 153126

Travel (1st year) 336 142128

Marketing costs 272 115236

Computers 246 103884

Other 233 98703

Liaison with health care providers 220 92961

Awarding body fees 194 82062

Training materials 172 72600

Cost of space for teaching 169 71445

Total cost of space for teaching 157 66231

Registration per student 144 60912

Workshops 139 58641

Uniforms 134 56430

Other costs for cadets (2nd year) 130 54990

Office supplies 129 54417

Cadets’ travel costs 127 53889

Overheads 117 49500

Other costs for cadets (1st year) 116 49068

Amount 100 42300

Occupational health costs 70 29601

Financial administration 65 27555

Prospectus 52 22011

Total cost of utilities 47 19800

Utilities 47 19800

Furniture 43 17985

Books (1st year) 35 14805

Books (2nd year) 31 13113

Stationery (1st year) 20 8460

Stationery (2nd year) 20 8460

Hand books 19 8217

Parking 5 2178

Total cost 18171 8187836

Cost estimates for high and low

value work

Cost per cadet and for all

33 Scheme (no value in work)

18171 8187836

Value of time spent on work

(year 1) LOW

�6000 �2538000

Value of time spent on work

(year 2) LOW

�4800 �2030400

Value of time spent on work

(year 1) HIGH

�7200 �3045600

Value of time spent on work

(year 2) HIGH

�6000 �2538000

Total cost (Low value of work) 7371 3619436

Total cost of Scheme (High value

of work)

4971 2604236

I. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–13181314

not available (often because budgets for cadet schemes

were part of larger training budgets) values were

imputed from data on other schemes. This did not

happen for the large costs elements such as bursaries and

costs of scheme leaders and training staff. Given that

some unit costs are imputed, standard deviations of unit

costs are not shown.

Schemes varied greatly in what was provided and at

what cost. For example, whereas the mean income of

trainees on the schemes was £5697 ($11,540) over the

whole period of the scheme, the highest paid cadets

received over £12,000 ($24,317), and in many cases

cadets received much less. The descriptions of the

payments also varied, with some described as bursaries,

some as grants and some as salaries. There was no

evidence that the higher cost schemes performed better

in terms of proportions of trainees going on to pre-

registration training in the health professions.

The costs have been calculated on the basis of 33

schemes and a total of 423 trainees in the first intakes.

There is probably an element of set-up costs in some of

the schemes included in the estimates, although an

attempt has been made to control for this in the case of

items such as the cost of training assessors, which was

adjusted to account for the fact that this would

inevitably be higher in the first year. Cost data are

available for the second and subsequent intakes, but

given the early stages of some of these they are not

included in the main cost calculations. Most of the

schemes were set up to last for 2 years (although in a few

cases they were for 1 year). The cost estimates are

averages for the schemes whatever their duration.

It is clear from the data reported in Table 1 that there

are only two large elements of cost—the cost of

bursaries or other funding for the cadets, and the costs

of the teaching, supervisory and mentoring staff, along

with their training needs. Based on the available data the

total costs for the 33 schemes represented here was

around £8 million ($16,210,885). This is better repre-

sented as around £18,171 ($36,821) per cadet.

3.2. Progression rates for the cadet schemes

Table 2 shows data on entry to cadet schemes from

data collected in the first survey of scheme leaders

collected between November 2002 and January 2003.

Data are presented in terms of the number of intakes to

schemes showing a maximum of five intakes from 1998

meaning that the longest established schemes had five

intakes.

It should be noted that the data presented in waves

are not, necessarily, contemporaneous. For example, an

intake described as ‘Intake 1’ refers to the first intakes of

students to those schemes regardless of whether or not

the schemes began in 1988 or in 2003. One of the factors

considered to be important was the length of time a

ARTICLE IN PRESSI. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–1318 1315

scheme had been established. Therefore, presenting the

data in this way permitted a comparison to be made on

this basis. Furthermore, some data from the first three

intakes is complete while more recent and current

intakes may still have been in progress at the time of

data collection. Despite the wide range of entrants to the

schemes and the diminishing numbers in the later

intakes, the average number per scheme is relatively

constant over five intakes (range 12.0–16.4).

Of the 56 schemes remaining at the time of the second

survey, 33 questionnaires were returned. Table 3

summarises information obtained on attrition and

progression of cadets in the second wave of data

collection for these 33 schemes.

Table 2

Entry to cadet schemes

Intake Number of

schemes

(max ¼ 62)

Number of

entrants (range)

Mean

(S.D.)

1 46 4–48 12.0 (6.74)

2 36 4–24 11.7 (4.39)

3 22 3–30 13.6 (7.03)

4 5 10–28 17.0 (8.03)

5 2 12–21 16.4 (6.36)

Wave 1 data collected between 1 April 2002 and 24 March 2003;

S.D., standard deviation.

Table 3

Student progression through the cadet schemes by intakea

Intakes 1st 2nd 3rd

Schemes (n) 33 27

Entrants (n) 423 305 1

Still on schemesc 105 57

Entrants (completed) 318 248

Attrition rates

Failure to complete 62 (19.5) 46 (18.5) 20

Completion rates

Successful completion of

course, n (%)

256 (80.5) 202 (81.5) 67

Progression to nurse

training—n (%)

159 (50.0) 122 (49.2) 39

Progression to AHP

training—n (%)

16 (5) 3 (1.2)

Progression to HCA—n (%) 29 (9.1) 30 (12.1) 13

Destination (other)—n (%) 52 (16.3%) 47 (18.9%) 15

aSecond wave data collected between 26 March 2003 and 31 JanuabData were collected in terms of intakes and data on most recent int

most recent intake is the 1st, 2nd, 3rd, 4th or 5th to the scheme. Ther

cadet schemes.c584 cadets were still studying at the time of data collection.

For the purposes of this evaluation, we use the term

‘attrition’ to refer to the percentage of students leaving

the cadet schemes without successfully completing the

course. A simple calculation of overall attrition was

utilised which took all causes of failure to complete into

account. The main reasons cited for failing to complete

the cadet schemes included: unspecified personal reasons

(73.8%), academic failure (9.4%), practice failure

(10.1%) and break of study (6.7%). Completion rates

refer to the percentage of students who completed the

scheme successfully, regardless of their future destina-

tion. Progression rates refer to the percentage of cadets

completing successfully and going on to pre-registration

training, but drawn obviously only from those schemes

which had finished. As nearly half of those who joined

the schemes surveyed were still on them at the time of

the second wave of data collection, progression rates are

provided only for 56.1% of total entrants.

Completion rates were high for schemes and ranged

from 77.0% to 91.7%. The data shows that for intakes

(1–3) the level of attrition is stable at around 20%.

However, for intake 4, the level of attrition is lower.

Intake 4 data come from much fewer schemes, as the

majority of organisations had not arranged four or more

intakes to their scheme by the time of data collection.

The data also shows that progression rates into pre-

registration nurse training is stable for the first three

intakes at around 45–50%, but that schemes on their

fourth intake report substantially higher figures, with an

4th 5th Most recent intakeb

(current)

Total

14 4 1 21

37 72 12 382 1331

50 0 12 360 584

87 72 0 22 747

(22.9) 6 (8.3) – 15 149

(77.0) 66 (91.7) – 7 598

(44.8) 53 (73.6) – – 373

0 1 (1.4) – – 20

(14.9) 3 (4.2) – 2 77

(17.2%) 9 (12.5%) – 5 128

ry 2004.

akes is spread across all five intakes depending upon whether the

efore, some of those shown as entrants are still participating in

ARTICLE IN PRESSI. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–13181316

overall progression rate of 73.6%. The authors therefore

consider that a reasonable estimate for progression rates

to nurse training for the most well established schemes

would be around 60%.

3.3. Cost per additional pre-registration trainee

The cost per additional pre-registration trainee is

sensitive both to the proportion who complete the cadet

course and progress to training and to the estimated cost

of the cadet course. Although progression rates were

relatively stable overall across the three intakes, there

was substantial variation in rates to nursing training

among individual schemes—from 100% of cadets

progressing in some schemes but only a quarter in

others. Due to this individual variation in progression

across schemes, cost estimations were performed using

projected progression rates of 45%, 60% and 75%. The

first estimation reflects the progression rates reported in

the first three intakes, and the latter estimates reflect the

trend identified of longer established schemes (intake 4)

reporting lower attrition and higher progression rates.

Table 4 shows the cost of producing one cadet taking

account of variable rates of progression into pre-

registration nurse training of 45%, 60% and 75%.

Assuming a progression rate of 45%, the schemes recruit

at a cost of £40,380 ($81,832) per place filled in pre-

registration training. At 60%, the schemes recruit at a

cost of $30,285 ($61,308). As the progression rate

increases to 75% the cost per cadet reduces to £24,228

($49,095).

This model assumes that there is no value in the work

carried out by cadets (or, more precisely, it assumes

that there is a need for all such work to be covered by

other staff).

3.4. Progressing to healthcare work

Although the most important objective for cadet

schemes was to ensure that students entered pre-

registration training in nursing, a secondary objective

valued by a number of cadet scheme leaders was to guide

Table 4

Cost per cadet progressing to pre-registration training and

healthcare work assuming differing progression rates during the

cadet schemes

Proportion progressing to

nursing education

0.45 0.6 0.75

Cost per cadet (£) 40380 30285 24228

Proportion progressing to

nursing or health care

work

0.55 0.70 0.85

Cost per cadet (£) 33038 25959 21378

people into healthcare work to take up health care

assistant roles from which a proportion may later

progress to pre-registration training. It may therefore

be considered a success that some people leave a cadet

scheme to take up this type of work.

Clearly, if those progressing to work as health care

assistants are included, then the cost per cadet ‘success’

will be lower. Table 3 shows that the number of students

leaving cadet schemes to become HCAs increases over

the first three intakes but returns to single figures in the

fourth intake. If, for the purposes of this analysis, we

estimate that approximately 10% of cadets began

working as health care assistants at end of the course

and we then include these students with those entering

pre-registration nursing training, cadet scheme progres-

sion rates overall could be estimated to be between 55%,

75% and 85%. If these rates are applied to the model,

then Table 4 shows that the cost per cadet drops to just

over £33,038 ($66,953) for a progression rate of 55% per

recruit to £21,378 ($43,323) if the progression rate is

estimated to be 85%. Again this model assumes that

there is no value in the work carried out by cadets.

Although the survey data indicate that all those who

progressed to HCA posts had completed their cadet

scheme successfully, it seems possible that some cadets

who fail to complete their scheme also become HCA’s.

In addition, there is no evidence for whether students

would have become HCAs had they not entered a cadet

scheme or whether they were already working in health

care before enrolling on the scheme.

3.5. Estimating cadets’ contribution to healthcare work

Cadet students on the schemes spend a considerable

amount of time working in health facilities and the

authors felt that some allowance for this should be

made. Although there is considerable variation across

schemes, the practical contribution of cadets to health-

care work is potentially substantial. To take account of

this input, two new models are presented to include this

work—the first estimating around 40% of cadets’ time is

spent in useful work (low value), and the second that

55% of their time is productive (high value).

Table 1 shows the cost per cadet when offset by a

low or high value contribution to healthcare work.

Table 5 shows that when using an estimated progression

rate of 60%, the cost is reduced substantially from

£30,285 ($61,269) to £12,285 ($24,853) or to £8,285

($16,760) depending on whether the cadet’s work is

assumed to have high or low value.

4. Discussion

Reliable information on the costs, attrition and

progression rates for other courses providing access to

ARTICLE IN PRESS

Table 5

Cost per cadet progressing to pre-registration nurse training

assuming differing progression rates and value attributed to

their practical work during the cadet schemes

Proportion progressing 0.45 0.6 0.75

Low value in work of cadets (£) 16380 12285 9828

High value in work of cadets (£) 11047 8285 6628

I. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–1318 1317

nurse training is difficult to obtain and it was beyond the

scope of this to collect such information independently.

We are therefore unable to say whether cadet schemes

provide a more cost-effective approach to progressing

students without traditional qualifications into nurse

training than alternative pathways.

What we can say is that the attrition rates of around

20% recorded for the first three intakes of cadet schemes

seem to be comparable with attrition reported for pre-

registration nurse training. Attrition rates on these

pre-registration training courses also show a similarly

wide variation between higher education institutions as

those found in the cadet schemes. For example, a recent

survey of 83 organisations found that within the pool of

nursing students due to qualify, attrition rates varied

from 7% to 50% across Higher Education Institutions

(HEIs). However, the calculated overall UK attrition

rate was 24.8% (Waters, 2006).

It is important to acknowledge that a considerable

proportion of the entrants were still studying at the

point of analysis. However, data so far suggests that

‘immature’ cadet schemes appear to progress just under

50% of cadets to pre-registration nurse education, but

that long established schemes have, on average, lower

attrition and higher progression rates of up to nearly

75%. It could be hypothesised that longer established

schemes are more successful in terms of selecting

students and at retaining them. The selection and

retention of students is possibly related, with better

selection leading to better retention. Certainly, there was

some evidence of improved selection procedures in

longer established schemes from the ten chosen for

detailed study in the second phase of the project. One

longest established scheme (Scheme 17) reported that

they had significant attrition in the early days of the

scheme but that retention in recent years was 100%.

When the value of work performed by cadets on

placement is offset against training, the cost per cadet is

greatly reduced. Using the estimate of a 60% progres-

sion rate, the cost per cadet is reduced from £30,285

($61,274) to £12,285 ($24,843) or £8285 ($16,761) per

annum, depending on whether the cadet’s work is

assumed to have a high or low value. This is a saving

of between £18,000 ($24,317) and £22,000 ($44,490) per

cadet. The magnitude of the savings made from taking

this work on placement into consideration is striking.

There is strong evidence that cadet students on the

schemes do spend a considerable amount of time

working in health facilities. Our survey of the leaders

of all 62 cadet schemes in England in 2002 showed that

cadets spend 26% of their time in the classroom (mean

22.5 weeks, S.D. 19.73) and 74% in practice placements

(mean 63.33 weeks, S.D. 29.40) (Draper et al., 2004).

However, as the evaluation did not include direct

observation of cadets in practice placements, we do

not know what cadets do in the important sense of ‘if

they were not there what extra staff would be needed’.

Even if such observation had been possible it is likely

that the findings would have been very variable across

schemes, making it difficult to derive a meaningful

average. In view of this, our approach was to model

alternative scenarios of the value of the contribution of

cadets to healthcare work during training. However, it is

equally possible that although cadets provide valuable

input to the services where they are on placement, they

may simply reduce pressure on existing staff without

having a substantial impact on the budget within these

service areas. In addition to this, the value of cadet work

is reduced by pressure on qualified staff to provide

supervision, by the uncertainty about student availabil-

ity and the need to ensure continuity of care for patients.

Further research therefore would be needed to ascertain

the impact of the cadets on the workforce arrangements

of the NHS services within which they train.

To date there has been little systematic tracking of

students beyond their entry to nursing or allied health

professional education. It is unreasonable to expect

individual schemes to monitor this, but during the study

period WDCs were inconsistent in gathering these data:

some gathered no data on progression of cadets, some

only maintained records while cadets were registered on

a scheme and others only up until cadets entered nursing

or allied health professional education. Ideally, records

should be maintained until cadet students have com-

pleted nurse or allied health professional education and

entered the NHS. Originally, the evaluation intended to

compare retention of cadets on pre-registration health-

care programmes with those students who had come via

other pathways. However, this proved impossible

because of the small proportion of cadets who had

progressed into pre-registration programmes by the end

of the study period, compared with those from other

routes, and the difficulty of identifying these former

cadets as individuals. We therefore do not have

information on how successfully cadets perform once

they embark on their pre-registration courses.

Unrealistic expectations of the nursing role have been

cited as one of the most important factors affecting

student’s motivation to complete their studies. One of

the suggested benefits of the cadet scheme is that they

provide students with a realistic picture of what working

as a nurse entails before training and that they may be

ARTICLE IN PRESSI. Norman et al. / International Journal of Nursing Studies 45 (2008) 1310–13181318

less likely to leave their studies because of unmet

expectations. However, cadet students who do not

possess a traditional academic background may require

additional support, both emotional and educational, to

successfully complete their pre-registration training.

Whether they receive this support will depend on the

sensitivity and understanding of the HEIs who recruit

them. It is therefore essential that further evaluations of

the schemes compare attrition rates for ex-cadets during

pre-registration training with those students entering the

same training but through different (both traditional

and non-traditional) pathways.

Another unknown is how long cadets who do become

registered nurses will work as such in the health service,

and whether this period will be longer, shorter or about

the same as professional nurses who are recruited

directly into pre-registration nurse programmes. One

assumed benefit of cadet schemes is that they because

they are established and managed locally, they are more

likely to recruit people who are committed to a long

career in a local NHS provider than direct entrants to

healthcare programme, but this assumption has yet to be

tested. In the past, nurses may have left practice, but

maintained their registration, with the result that

making accurate estimates of the mean length of a

nurse career have been virtually impossible. A recent

requirement of continued registration with the UK

Nursing and Midwifery Council, however, is that nurses

are required to be in practice and may be asked to verify

this. In future, rates of de-registration due to lapsed

practice may provide the best indicator of the mean

length of nurses’ careers, and may allow comparison of

former cadets with non-cadets. We would also suggest

that a standard method of maintaining records across all

cadet schemes be introduced. With such a method in

place there would be the opportunity for further

longitudinal work to evaluate fully the progression of

students through cadet schemes and beyond and there-

fore look in more detail at the long-term cost-effective-

ness of these schemes.

A final consideration is the unaccounted for value of

cadet schemes in widening access to the healthcare

workforce by attracting into healthcare work those who

might not otherwise have been recruited, and reducing

social exclusion. The evaluation suggests that NHS

Cadet Schemes have been partly successful in widening

access to healthcare study (Watson et al., 2005), but

attributing a monetary value to this goes beyond the

remit of this study.

5. Conclusion

In sum, the mean cost of producing a cadet who

progresses successfully onto a pre-registration nursing

programme depends substantially on the value of their

contribution to healthcare work during training and the

progression rate of cadets through the scheme. The lack of

comparison data means that we cannot say whether cadet

schemes overall represent good value for money compared

with other access schemes which facilitate access to nurse

training. However, the study suggests that as cadet

schemes become more established, they improve their

understanding of retention and selection, and become

more successful at achieving their main goal of progressing

students successfully to pre-registration nurse training.

Disclaimer

This work was funded by the Department of Health,

England, UK. The views expressed in the publication are

those of the authors and not necessarily those of the

Department.

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