Assertiveness is a necessary quality in student nurses as it enables them to successfully advocate on behalf of their patients. Hierarchical structures within ward settings negatively impact on assertiveness and may dissuade students from speaking out about poor practice. This article describes a critical incident which took place while the author was a student mental health nurse on practice placement. The perspective of the student nurse offers an insight into social structures present within ward settings, and provides a consideration of the nurse's role in terms of benefit offered to the patient. Evidence suggests that student nurse empowerment is closely related to job satisfaction, motivation for learning and positive regard for practice placement. The author suggests recommendations for student nurses in similar situations and, through reflection, highlights other possible implications for future practice.
A recent article in Nursing Times featured Helene Donnelly, a staff nurse reportedly ‘too scared to walk to her car’ because she felt threatened by her colleagues. The article described how a ‘culture of fear’ developed on the ward as a result of Donnelly's decision to speak out about poor practice (Calkin, 2011). While this is a particularly extreme example, the notion of‘feeling intimidated’ may be a phenomenon familiar to many within the nursing team. The nature of nurse education is such that, in practice, students are likely to encounter situations that push them to the very limit of their comfort zones. Speaking out on bad practice is one such unenviable scenario.
Koontz et al (2010) describe the clinical learning environment as, ‘the most influential context for gaining skills and knowledge’ among student nurses. Workplace dynamics and hierarchical structures within this environment may contribute to student nurses feeling too intimidated or embarrassed to speak up for themselves or their patients. This incident also provided an opportunity to consider the role of the nurse in terms of ‘usefulness’ for the patient and the implications of this for student nurses. Ultimately, this analysis looks at ways in which the student nurse may deal with situations such as these and may empower others in similar situations. Identifying particulars will be removed throughout to maintain patient confidentiality in accordance with Nursing and Midwifery Council (NMC) guidance (2008).
Description The patient was a 78 year old male suffering chronic grade 4 pressure sores. His nursing care was complicated by a spinal injury, which had resulted in lower limb paralysis and double incontinence. Grade 4 pressure ulceration is a common and often unavoidable secondary complication for patients who have sustained a traumatic spinal cord injury (Warren, 2010). I was asked to assist a staff nurse in cleaning and redressing the patient's wounds using an aseptic procedure. Two nursing assistants were also present for the procedure as the patient had to be repositioned specifically to allow access to the wound sites.
It became apparent during repositioning that the original dressings had become soiled owing to a continuous flow of faeces near to the wound sites. At this point the patient's incontinence pads and original dressings were removed and he was cleaned of faeces. With no change of gloves after attending to the patient's hygiene needs, the alginate wound packing was picked up and motioned as if about to be used on the wound site. I immediately had concerns about the high risks of infection and long-term health consequences and so suggested that the nurse undertaking the procedure might want to change gloves before continuing with the procedure. Consequently the gloves were changed and the procedure completed without incident. The patient was aware of the situation and made comment about this to the other members of the multidisciplinary team. The situation stimulated a range of feelings. I felt acutely embarrassed that my intervention had not gone unnoticed by the patient. I worried that the patient might lose confidence in the quality of his care because of what I had done. I wondered whether I should have kept quiet throughout the incident and that perhaps my intervention had done more harm than good. Ultimately, I was left questioning the function of my role as a student nurse on the ward.
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Beneficence Nurses have a duty of care to their patients and clients who are entitled to receive safe and competent care (NMC, 2008). Ethically, the nature and definition of the nursing profession dictates that we must always act for the benefit of our patients. The opportunity to assist another staff nurse in dressing the patient's wounds (on a separate occasion) provided a good indication of current best practice in this clinical area. This nurse adhered to the principles of ‘clean’ technique, substituting sterile for clean gloves. It has been suggested that chronic wounds such as leg ulcers may be treated with a ‘clean’ technique as opposed to a wholly aseptic procedure. A clean technique has the same aim as an aseptic technique but uses clean—rather than sterile—gloves (Unsworth, 2011).
Ultimately, the same principles underpinning aseptic procedure should be followed. These include ensuring the professional's hands are clean and adopting a non-touch technique to ensure susceptible sites are not contaminated with microorganisms (Pegram and Bloomfield, 2010).
Bree-Williams and Waterman (1996) found that 33% of nurses contaminated their hands and equipment during the aseptic technique procedure, due to factors such as poor glove technique (Flores, 2008). The author suggests that for an action to be termed non-beneficial, there would have to be evidence of real potential for patient harm. Using this definition, the notion of beneficence is not an unrealistic expectation of all nurses. The staff nurse's actions had potential for harm to this patient due to the very real risk of infection. An adequate immune response is essential for successful wound healing (Moore and Cowman, 2007). The patient's immune response was compromised due to his advancec age, his diabetes, and his unwillingness to partake in a nutritionally-balanced diet. The necessity of keeping the wound sites clean was therefore of the utmost importance as he was already at heightened risk of infection. In neglecting to change gloves, the staff nurse was potentially introducing faecal matter to the sterile field and consequently to the patient's wound sites.
For individuals with leg ulcers, infection contributes to a significant increase in morbidity, resulting in poorer clinical outcomes and substantially greater treatment costs (Moore and Cowman, 2007). Attention is drawn to the relationship between infection and mortality from the very beginning of nursing training. Indeed, promoting the prevention and control of infection is a key concern for health services in Scotland (NES Education for Scotland, 2011).
Analysis Ultimately practitioners need to make sense of an experience, thereby improving future practice (Kenzi-Sampson, 2005). Effective reflection on this incident involved an attempt at explaining, or making sense of, the staff nurse's actions. What factors may have prompted the staff nurse to carry out this procedure in this manner? Upon investigation of nursing literature, several possible explanations present themselves. The nurse may have been nervous at having to carry out this procedure in front of ‘an audience’. Indeed, Matsumara et al (2004) suggest that the clinical nurse may feel threatened when working with students. Perhaps the presence of a student in observing the procedure was instrumental in the nurse's forgetting to change gloves. Or perhaps the omission was deliberate. Indeed, some nurses feel that aseptic technique is of limited use in some instances.
‘One of the reasons for non-compliance with aseptic technique is because the individual cannot see micro-organisms with the naked eye.’
(Preston, 2005) The author is inclined to reject this hypothesis given that a basic knowledge of infection control is a prerequisite for all nurses regardless of their branch of training:
‘Good aseptic technique is essential for all nurses, regardless of their branch or field of practice.’
(NMC, 2008) Day et al (2007) suggest that mental health nurses have a tendency to attribute physical symptoms to a psychological cause due to, what they suggest, is a mind-body split in mental health nursing practice. The authors go as far as to suggest that this ‘diagnostic overshadowing’ may be responsible for a deficit in the quality of wound care. Certainly, a commonly held belief on the ward was the notion that the patient's ‘self-neglect’ was the perpetuating cause of his leg ulcers. The author would be reluctant to suggest that this belief contributed in any way to the quality of care the patient received, however.
Consideration of a patient's individual needs and their comfort must be a priority when performing any clinical procedure. There should be a focus on communication, physical care needs, privacy and dignity (Pegram and Bloomfield, 2010). It could be argued that the staff nurse's actions in this instance were not beneficial since in carrying out the procedure the patient's safety was compromised. The law states that reasonable care must be taken to avoid acts or omissions which can be foreseen as likely to injure (Kenzi-Sampson, 2005). Yet human nature dictates that we cannot do everything perfectly all the time. It may be reasonable, therefore, for staff nurses and students to make mistakes on occasion, provided they recognise these and take steps to prevent the error from happening again.
(Bradbury-Jones, 2007) It was evident from the very beginning that the staff nurse was not particularly confident in the skills required to competently carry out the procedure. The nurse did not appear to know what equipment would be required and looked to the author for advice on several occasions before beginning. In hindsight it is obvious that the author should have intervened at this point to state that she was not comfortable in carrying out the procedure, at least until the proper way to carry it out had been ascertained. So what stopped the author from saying something before the procedure began?
Admittedly, it seems to have been a combination of lack of confidence, fear of reprisal and faith in the knowledge of superiors that prevented any earlier action. The author's lack of confidence and allowing this fear of reprisal to influence behaviour is particularly uncharacteristic of my personality. Kanter (2011) maintains that social structures in the workplace influence employee behaviour and attitude to a greater degree than individual personality characteristics (Casey et al, 2010).
A literature search reveals that empowerment in relation to registered nurse practice is a well researched field, however relatively little has been written on the subject of empowerment specifically in relation to student nurses. The Critical Social Empowerment theory describes nursing (among other professions) as a ‘bastion of unequal distribution of power and privilege’ with certain members in a subordinate position (Casey et al, 2010).
Bradbury-Jones et al (2007) suggest that power is present in every nursing situation due to these hierarchical structures. They go on to document ‘a lack of respect shown to nursing students by registered nurses’, and even the notion that ‘nurses eat their young’. As a consequence, it is understandable that student nurses be nervous of speaking out on poor practice given their ‘place’ in the clinical environment.
It is evident from this experience that even the patients on the ward are aware of the subordinate position of the student nurse. The nursing assistant who helped to reposition the patient during the procedure was acutely aware of this social hierarchy. When the nurse left us in the room with the patient she advised the author that it was a ‘bad idea to tell (the staff nurse) what to do.’
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The author was left questioning the real function of this hierarchy if it had even managed to silence experienced nursing assistants. One had to wonder if her silence was due to previous repercussions from speaking out on behalf of patients. Nevertheless, it is the duty of the experienced professional to question the practice of another if they believe inappropriate treatment may harm or be detrimental to the patient (Kenzi-Sampson, 2005).
How then are student nurses to reconcile their practice within these confines and find a satisfactory method of working? If the aim of preparatory nurse education is to equip nursing students with skills and knowledge that enable safe and effective nursing practice (Meechan et al, 2011), then a necessary skill must be the ability to recognise and question unsafe practice. However, the author would suggest that it might be difficult to advocate on behalf of a patient if we cannot advocate on behalf of ourselves. Within the context and perspective of the recovery approach, we need to be able to assist patients to ‘have control over and input into their own lives’ (Scottish Recovery Network, 2011). A staff nurse must have at least some measure of control over the quality of care given to patients in order to practice safely. It is therefore reasonable to suggest that we might need to build upon our own assertiveness to most effectively assist and advocate on behalf of those in our care.
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Conclusion A positive correlation between student assertiveness and psychological empowerment was found in a peer-reviewed behavioural study carried out using input from 207 student nurses (Ibrahim, 2011). Empowerment itself has been found to be strongly correlated with job satisfaction (Casey et al, 2009). This suggests that if the author had been more assertive she would have felt more comfortable in questioning the staff nurse and perhaps agonised less over the outcome of the intervention.
The consequences of nursing student empowerment are high self-esteem, motivation for learning and positive regard for placement (Bradbury-Jones et al, 2007). Several factors including—but not limited to—assertiveness and having a satisfactory knowledge base appear to contribute to empowerment and related job satisfaction in student nurses. Extensive research would need to be carried out to ascertain the function or purpose of social hierarchy in ward settings, specifically in relation to NHS hospitals in the UK, though research from other fields of practice has proven useful to an extent.
Ultimately, assertiveness is a necessary quality in student nurses, to enable them to confront injustice and act as true advocates for their patients, especially in a hierarchical ward setting. Hierarchical structures should not interfere in providing the best service that patients deserve (Johns, 2010).
Implications for practice Greenwood (1998) suggests that reflective thinking ‘seeks to analyse many situations of professional performance so that they can become potential learning situations and in effect the practitioner can continue to learn, grow and develop in and through their practice’. Hunter (2010)further suggests that reflection can ‘help bridge the theory practice gap’. This exercise in reflection has helped the author to recognise some of the complexities inherent in making this link. A closer look at student empowerment revealed that a lack of assertiveness on the part of student nurses can be detrimental to their patients. Yet theoretically we must always advocate on behalf of our patients, and feel confident in speaking out if we witness poor practice.
In the author's experience it is fear of reprisal and having to continue to work in the same environment that might prevent student nurses from reporting incidents of inappropriate treatment. Also, the novice level of skill and knowledge of student nurses may prompt blind faith in the actions of superiors. This incident highlights the importance of students being confident in their ability to speak out on poor practice promptly, and with a clear voice. Nurses who are able to utilise their own experiences, to enhance personal knowledge, are in a better position to manage the needs of their patients).
The NMC has additional resources available in the form of a ‘toolkit’, designed to ‘facilitate discussion and promote the importance of raising and escalating concerns’ (NMC, 2011). Essentially these have been adapted from NMC guidance on escalating concerns in practice and can be adapted for different care settings. While this would have been of limited use in this particular incident, it ought to provide a valuable resource for any concerned member of staff regardless of their position in ward hierarchy.
All staff should be able to feel confident in speaking out on bad practice without fear of reprisal, although this is, admittedly, sometimes easier said than done. A member of staff's position within the workplace hierarchy should not influence the likelihood ofthat staff member advocating successfully for good practice.
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