Student nurses are instruments of cultural change

On Wednesday evening a packed Edmond J Safra lecture theatre King's College London heard the inaugural lecture from Professor Jill Maben titled "Care, compassion and ideals: nurses experiences of nursing". Jill is the Director of the National Nursing Research Unit at King's and is a well respected researcher of nursing. She also just happens to be my PhD supervisor.

I won't recount the entire lecture, hopefully at some point a transcript will emerge because what Jill presented to us were the key research projects that she has undertaken over the last 16 years. All of which are surprisingly resonant in the context of the Francis Report.

Reference was made to Austin Thomas's excellent speech at the RCN Congress last week, where he spoke of his experiences of being nursed during his 30 operations, following a motorcycle accident. Austin had spoken of the nursing staff as 10% bad, 10% good and 80% indifferent due to 'care fatigue'.
I wasn't in the audience at congress when this was stated, but I can imagine a collective sharp intake of breath in the auditorium by some, and nods of agreement from others. I would have put myself in the former category had I have been there instead of having watched the webcast.
When we nurses talk about nursing these days, the image of the nurse seems to fall into two categories:

• Nurses are failing in their duty to care for their patients and lack the core values that we have traditionally associated with the profession.
• Nurses are caring and compassionate by the virtue that they have chosen this career but are operating within organisational constraints that prevent them from doing what they know is right for their patients.

The implicit assumptions that underpin these two opposing views of nursings professional identity are that nurses either come in to the profession with the wrong values and they do not attain them whilst students, or that nurses our powerless to be the type of nurse that they wish to be.
Internal locus of control in the first, external locus of control in the second.

Professor Maben feels strongly that nurses do come into the profession with the right ideals and values for nursing, and that the sustainability of these values is dependent on the culture in which students and professional nurses find themselves working. The culture on the wards and in the environment in which the nurse finds themselves will correlate with the fate of the nurse's values and ideals. 

Furthermore, she found in her doctoral research that there were certain 'covert rules' within nursing culture that would affect the developing identity of the nurse. These covert rules included 'getting the work done' (focusing on tasks that have to be achieved in the working day rather than being patient-centred), and 'not rocking the boat' (accepting the way things are and not 'creating a fuss'). 

The first of these covert rules reminded me of a morning shift that I did on a busy acute medical ward as a first year student. The ward was run by a formidable but inspirational ward sister. I had been allocated to care for a group of 5 patients, most of which were 'self caring' and one who needed full assistance with hygiene  We all set about our tasks of ensuring that our patients were washed, dressed and sitting out of bed. I was having one of my super-efficient days and by about 10am all of my patients were sitting in their chairs looking clean and fresh. Being keen to impress the Sister and to get a good ward report I cheerfully informed her that my work was done, to which she paused momentarily and said "hmm.. you've finished have you? Is that all that nurses do? Wash and dress patients?".

Of course, I realised straight away that I had made the error of conforming to the idea that nursing is only about getting tasks done and that I had overlooked the fact that the patients were not just here for the benefit of giving me something to do. I didn't have a clue what my patients actual needs were beyond the task of washing and dressing. 

"Go and talk to the patients to find out what their needs are, then come back and tell me that you have done your work!".

Feeling somewhat chastened I duly went off to talk to each of my patients. I found out about their medical conditions, their treatments, what they were feeling and were afraid of, how they felt about what was happening to them and what the future held. By the end of the shift, I really felt that I knew about the scale and complexity of the patients' needs and (although I didn't yet have the answers) what they needed to have put in place for them.

I had conformed to a previous role of being an auxiliary nurse in which my primary purpose was to get the jobs done. A role in which there was no real requirement for me to do anything other than washing and dressing.

When time is short, resorting to this task-orientated approach to nursing is commonly observed. Just get the jobs done and if there is time left over, then you can look and see if there are other needs that have to be met. 

I was lucky enough to have been in on a placement where the culture actually valued nurse-patient interaction as a means of identifying patients needs. To sit with a patient to talk to them was not seen as slacking-off, but as nurses doing what nurses should be doing.

Sadly, a few years later I bumped into the Sister in town, she told me that she had left nursing as she could no longer find the energy to deal with the stress of providing care for her patients and that financial and staffing constraints were reducing her ability to be compassionate.

The culture on that ward opened my eyes to what nursing can, and should be. I wonder if I hadn't have had that experience how it might have shaped my identity as a nurse? I wonder if I would have become a functionally competent but emotionally disconnected nurse?

The covert rule of not rocking the boat is one that really concerns me. The obvious sequlae of this would lead to a situation like the one that was revealed at Mid Staffs NHS Trust. But I worry that this is only a part of the story. Yes, we all look at the Francis Report and shake our heads at just how bad situations can get when staff concerns aren't heard. This is a high profile indictment of a failing organisation. But, before you get to a problem of that magnitude there will be a slow, steady erosion of the organisational culture. And that starts more locally; within individual teams on individual wards and units. 

Students have come to me in the past to express concerns about things that they have seen in practice. Often, these are not cases of negligence or professional incompetence that have formal routes for reporting. More commonly these situations that are intangible and hard to articulate. To raise them as problems might seem to be an overreaction on the part of the student, and might lead to the student to be labelled as a troublemaker or 'a bit precious'.

I always try and get the student to explore what it is that has made them feel uneasy about the situation. I ask them which of their values and ideals are being challenged by what they have seen or heard. However, when I suggest that they raise these concerns with their mentor in practice I inevitably get the same response, "I don't want this to affect my assessment in this placement", and often they decide to keep quiet and just see out the rest of the placement.

Yes, some students will not necessarily make complete sense of what they are seeing or understand all of the factors that influence some of the situations that they find themselves in. But that doesn't mean that they shouldn't be listened to. After all, you could say the same about patients but that doesn't stop us from actively asking them about their experiences of the care the receive. 

If for example, a student hears a nurse speaking about a patient in a way that overlooks some important aspect of their care needs that the student feels should be considered, what is the student to do? The easy answer for us, as registered nurses is to say that they should speak up. But students often find this very difficult to do. Some students have said to me that before speaking up they would need to be able to articulate their point well otherwise they might be put down as not knowing what they are talking about, or feel that they are being difficult.

Cultural change in the NHS has been a major focus of the Francis report recommendations. But culture in the work place is not ubiquitous and is complex and context dependent. There is not a one-size-fits-all method of changing culture. We have to start by changing culture locally first it seems.

I believe that students can, and should be at the heart of changing the culture in practice. They are still learning but they can offer insights into practice that they have accumulated from recent experiences on other placements and from their learning in university. Students are just full of ideas and insight. So much so that they are nearly fit to burst sometimes!

Instead of just teaching them and signing off their competencies, perhaps we should be actively asking for their thoughts on patient care and actively involving them in the future direction for providing that care. When this happens the students benefit from being taken seriously, the ward/practice area benefits from developing a more fluid and dynamic attitude to nursing, and ultimately the patients benefit from a workforce that is constantly trying to change and improve in response to patients needs. 

We should allow students and nurses to rock the boat and give them a platform for challenging practice.

If their perspectives are wide of the mark then that is a good opportunity for their learning, if there is some validity in what they are saying, work with them to find ways of changing practice. But the first thing to do is to listen.

Professor Maben's work highlighted that the fate of nurses' ideals and values as being either sustained, compromised or crushed. The figures of which appear to correlate with Austin Thomas' 10% bad, 10% good and 80% indifferent. She concluded by suggesting that our efforts should be focused on the 80% indifferent rather than the 10% bad. If we can change the culture to encourage and motivate the 80% then suddenly these figures look more like a 90%/10% split, which is a very good start indeed!




(My own opinions expressed here, not necessarily anyone elses!)