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Rising to the Challenge: A Student Nurse writes about the Care Maker experience

June 23, 2014

A guest blog by @NurseVink

I am a nursing student at the end of my second year. On my last placement, my mentor gave me the nickname Spaniel because she felt I was very (too?) enthusiastic about everything there was to learn. Initially I took this as a compliment but as time went on, I got the feeling that what she actually meant was: Give it a rest and calm down. I would catch part of a conversation about a patient and pipe up: Oh, I spoke to her daughter earlier today and she asked blah blah blah. As far as I was concerned, this is part of good patient care. I merely passed on some information about a patient, even if this patient wasn’t strictly ‘mine’. At the end of my placement, I was told: This ward ran fine before you got here and it will run fine after you have left, so just focus on your own learning and do not get involved with other nurses’ patient care.

Stick that in your pipe and smoke it.

As it happens I am also a Care Maker. I subscribe to the concept of The 6Cs: Compassion, Care, Communication, Competence, Commitment and Courage. I really believe that you can not be a good nurse without applying these values. Needless to say that after my last placement, Courage has dropped off my radar and I no longer feel I am able to apply the 6Cs in practice. I am sure I am not the only student who feels this way and I am also sure there are many qualified nurses who want to challenge practice or behaviour but find they lack the Courage to do so. Yet from day one at university, it is drilled in to us that we are the New Generation. That we have the opportunity to improve practice. That it is our duty as a nurse to speak up when we see things that are unacceptable. That Compassion is the most important thing in nursing. That Communication is vital between nurse and patient.

What about communication between nurses and other health care professionals?  It is incredibly daunting as a student nurse to stand next to a consultant who is prescribing a daily dressing change of Cutimed Sorbact for a leg ulcer when I know from my experience in community nursing that this is highly likely to disturb the wound bed even more. In a case like this, it is probably better to change the dressing less frequently. But when the consultant says: I am not very familiar with dressings so let’s do this for a few days and see what happens, what am I supposed to say? I have already tried to bring up that maybe a different regime is better for this patient but the consultant ignored it. I go to my mentor who says: yeah, doctors don’t know anything about dressings. But nothing is changed. Nor is it explained why not. How many times do I ask about this before I start sounding like an arrogant student who thinks she knows it all? How can I apply all of the 6Cs here? The two I am missing are Communication and Courage. I do not have the courage to take this further because I do not have the communication skills to do that.

So far in my university education, I have not received any training at all on how to challenge other health care professionals, despite being told all the time that this is my duty as a nurse. We are told our future registration is on the line if we allow or participate in bad practice. But how? How do I challenge? What do you say? To whom? And when? What words do you use? How many times do I bring evidence to that doctor and say: please read this report about dressing changes, Doctor. We are told we need to challenge in the right way, at the right time and in the right tone. But what are these things? What words do you use? No elaboration on this. No explanation on why it can be extremely threatening for people to be challenged in their practice. Nothing to foster understanding of the minefield of emotions on both sides. It is hard enough to say to someone that their practice is outdated but at least you can, to some extent, come up with evidence to show them they need to change their ways. However, challenging someone on their use, or non-use, of the 6Cs is infinitely harder because there is no definition, no yard stick, nothing to judge it by. I believe all nurses think they apply the 6Cs. If they didn’t, they wouldn’t be a nurse. No nurse says: I am not compassionate but I am very good at communication.

Challenging bad practice is challenging someone about their skills and knowledge. You challenge what they do. Challenging someone on their care, courage and compassion is a whole different ballgame. You’re not telling people they need to change how they work. You are telling them to change who they are. When I joined up as a Care Maker, this is what I hoped I would learn: how to inspire other people to think more critically about themselves and about how they feel they are applying those 6Cs in their every day work. It is not enough to say: I am a 6C Champion and you should be too. In fact, if I was a nurse with 15 years experience, I would be extremely offended if some young nurse tried to tell me I should be more caring.

Just recruiting people as Care Makers will not bring about any changes. How is a stall at a conference going to change practice? Me wearing a t-shirt that says Care maker is not going to make someone else a better nurse. In an ideal world, each and every health care professional should want to be a Care Maker and subscribe to their importance. After all, they are such simple concepts it is almost insultingly simple to reduce nursing to just 6 words. The Care Makers project should offer tangible things to people who want change. And at the top of that list for me is training on how to open up conversations with other people about changing practice and behaviour. Being a Care Maker should not be the end of the process. Being a Care Maker should be the start of a process where people get training on how to talk to others about their practice. It should be about me learning to say: Doctor, I have brought this piece of evidence about this dressing regime. I would appreciate it if you read it and maybe spent 5 minutes with me at lunch time to discuss it, because I feel the patient would benefit more from a different regime.

Every day at university we are taught how we need to be able to explain why we do things the way we do them. That we need evidence for everything. Yet we are not given any evidence or training on how to say to others: You need to change what you do. From my own experience at my last placement, I can tell you that if we do not get this training to help us build up the courage and communication, the remaining 4Cs are hard to maintain. Because if I do not have the courage and communication skills to stand up for my patients, their care will suffer and pretty soon, compassion fatigue will set in and my commitment to nursing will be replaced with disillusion, which will lead to my competency to practice being at risk.

The Care Maker project offers nothing tangible that helps people to improve practice. With university curriculum already being overloaded, it would be an excellent opportunity to turn the 6C campaign in to something that gives people the skills to not just tell other people about them, but also the tools on how to do this in a way that will actually change things. At the moment, all the Care Maker project seems to do is create a large group of people who say: we want to improve things. This is how every revolution has started in history. However, there needs to be something behind this willingness to change, something that helps people to actually make that change. And for this nursing student, communication training and assertiveness training would be an excellent place to start. Maybe with student forums? Maybe role playing? Perhaps invite nurses and doctors to tell us how they would like their practice challenged? Sign me up.

  1. I was a care maker. At present I have voiced my views on this quite clearly at uni and I have decided to use the Salford University name rather than the Caremaker one. I cannot say too much as my views are awaiting publication – needless to say agree entirely. However, creating a student folder today I still put this Caremaker stuff in for others to view as it may be the role for them. Just not for me

  2. Thank you for commenting. There certainly seems to be a lot of debate around this issue at the moment, which is healthy and shows that nurses are thinking hard about how we can take the profession forwards. I am proud to have hosted @NurseVink’s post – what a terrific contribution she has made. I wish the Salford group every success and look forward to hearing how you are working to further the cause of nurses and nursing – and of course patients.

  3. First year student nurse, curious, questioning, cynical (when I need to be) care maker.

    Don’t think that I signed up to wear rose tinted specs when I joined the 6 Cs ‘scheme’. But I didn’t expect that joining the care makers was going to hand all my learning directly to me on a plate and make it all easier to swallow.

    I joined that happy, smiley bunch of student nurse care makers firstly within my own university, because I hated what I saw on my first placement. I wanted to run screaming back to that cushy, warm pillow of a previous life as a secondary teacher in an inner city school and working with teenage parents in socio-economically deprived areas. Yes, that bad.

    I did not challenge whether another nurse was compassionate, caring or courageous.

    I challenged the fact that bad practice was inherent within the setting. Surgical gloves used as stoma bags, allowing incidents between residents to escalate to violence through lack of early intervention, watching mucky, acrylic nails pop pills into multiple residents mouths without a trip to the hand washing basin in between.

    I wanted to get with that positive bunch of folk that weren’t shying away from getting more involved with joining a conversation about compassion in practice.

    You say you’re not telling people that they should change how they work, you’re asking them to change how they are. Well, I would not be so arrogant to do either. I’m learning and part of that process is asking questions. If I last until 2016 and qualify, I will continue to ask questions in a respectful, polite way until I get the answer and the evidence behind it. A bit like a well mannered dog with it’s proverbial bone, but with very sharp teeth.

    Who is suggesting that care makers should be so crass to pass judgement about whether an experienced health care professional is caring or not? Don’t think that’s written down anywhere on the care makers hub. Again, it’s about how you learn, not about right and wrong, black or white.

    So, how to apply the 6 Cs in practice when the going get tough on placement and in the work place? A good question, which I think you’ve already answered. No one way will do it.

    I agree that up to press we have not been ‘given’ the communication skills within the academic input of our training. Practical skills such as assertiveness training, negotiation, mediation and conflict resolution would be welcomed by me, and that’s just for dealing with other student nurses in my cohort.

    So, may I suggest as care makers we raise this issues with our universities, as we have reflected on our practice and found that we have gaps in our ability to work effectively as part of the multi-disciplinary team? That wording should just about do it to start with.

    Again, I agree, t-shirts and standing at the side of a stall enlisting more people committing to improve health care (who would have thought it?) changes nothing. But thinking about how you as a student nurse want to nurse, what you need to learn to do that and then doing it will.

    You are I are the Care Maker project. How about we get our heads together, do some research to get some evidence based communication programme ideas and then put forward a proposal to care Maker HQ to facilitate some training to address the gaps you have highlighted in our education?

    Hey, I know… let’s do something else really positive instead of sat here on’t tinterweb opining at each other. Let’s write a really catchy song, get it to number 3 on that I tunes thingy, raise shed loads of money for a cancer charity aiming to improve patient experience and really join the conversation about compassion in practice.

    Oh heck, it’s already been done…back to blogging then….

  4. @NurseVink permalink

    Thanks for your reply. I agree with many of your points: we are the people to change things. I am not at all against the Care Makers scheme (heck, I am a Care Maker, remember). My point is that what they wanted was to recruit 1000 people, Care Makers, who would be specific ambassadors to promote the 6Cs to others. To me, that means: The Care Makers are expected to tell other health care staff that they need to apply the 6Cs in their day-to-day work. That implies that a Care Maker should be willing and able to challenge those who are not applying the 6Cs. Or at least that a Care Maker should be able to open up conversations with other health care professionals about how to use the 6Cs more. I feel that in order to do this, they need some kind of training in communication etc. And I thought that was part of the Care Maker scheme.

    I do not expect my learning to be handed to me on a plate. I am not sure how my blog post suggests that I do not go out and do other things to enhance my learning. We are all responsible for enhancing our learning. However, if I am recruited for a job that I think sounds exciting, I would normally expect to receive some training to be able to perform that job. That is not laziness. Maybe I misunderstood what a Care Maker is supposed to do. I did not think it was a small group of 1000 people who were going to be tasked with doing things that improve things for patients in their own nurse-patient interactions alone. I thought the point of the 1000 recruits was that they should go and help spread the importance of the 6Cs to other health care professionals and that they should engage others in conversations about the 6Cs and thus not only increase awareness of the 6Cs, but more importantly, play an active role in actually helping people to IMPLEMENT them in their work. If this is not the case, I stand corrected.

    Incidentally I think discussions on the internet are vitally important to improving things, as long as they get followed up with actions. Nothing ever got improved without people first pointing out that improvements may be needed. As many recent investigations in poor care have demonstrated: ignoring things that need improving in favour of only ever pointing out how great other thigns are can lead to failure. The only way long lasting changes in ‘culture’ can be made is not just by preaching to the converted at events for Care Makers but by respectfully reaching out to those who need to review their practice and approach to patients. I believe nurses are much more likely to change their own approach if it comes from a conversation with colleagues, than when management puts up posters that tells people to be more Compassionate.

    Many Care Makers do wonderful things. Meet up, organise things such as Stop The Pressure in Leeds recently etc. Finally, I applaud the young man who made the Care Maker song to raise money for charity. Certainly shows application, dedication, compassion and all the other Cs. However, the next step remains a question that is still unanswered for me: whilst the song raises the profile of the 6Cs, but what do we DO with that raised profile? As I said before, the 6Cs are so blatantly obvious as a concept that I bet all nurses think that they already apply the 6Cs in their work (which they should!!) Even those that others might think really don’t. I thought the Care Maker scheme was devised to open up conversations between staff an thus enhance a culture change from the bottom up. And if this is what a Care Maker I supposed to do, I assumed there would be more structured support to enable them to do this. That was the main point of the blog.

    • Again, I agree with most people’s points. I’m not particularly active as a care Maker, but the point I’m making is if we see a gap in the initiative, let’s open up a conversation with Care Maker HQ to see if we can address what we can do to get to where we want to be.

      Let’s channel any feeling of frustration into action.

    • Barbara Bradbury, Halland Solutions permalink

      I have read these posts with great interest. For the last 15 years I have been designing and delivering leadership, management and personal development programmes and services for nurses and other health care professionals. Communication and assertiveness skills are at the heart of the work I do. I have worked with many hundreds of people in health care, from Health Care Assistants to Directors and Chief Executives. Much of the work I do with coaching clients and in the programmes I run is on how to communicate more assertively and be more influential.

      I suggest that no one would like to be “told” that they are not compassionate, caring, committed, competent or courageous. You might add considerate, courteous, respectful, kind and thoughtful to the list. Of course, these are all behaviours that you might expect of any health care professional. If they are not evident, pointing this out to someone will simply antagonise them and make them less willing to question their own behaviour. Challenging people well requires one to ask open questions, inviting thoughtful responses.

      When I was a student nurse on my first ward, back in the 1970s when you weren’t expected to question anyone, I had an encounter with a Consultant. I shall never forget it, because I was furious with the outcome. He tried to humiliate me in front of patients, the nursing staff and his medical firm. I was frogmarched down to the sluice, at the far end of the ward, to demonstrate my ability to read the SG of a urine sample. (You probably don’t do this these days – the patient in question was under investigations for Diabetes Insipidus.) When I was proven to be accurate in my readings he said nothing and stormed off with the entourage in full flight behind him, and I was left alone in the sluice. I washed the kit whilst collecting my thoughts and calmly walked back up the entire length of the ward, head aloft, and waited at the end of the bed until he had finished consulting with that patient. The ward Sister asked me what I wanted and I said that I was waiting for an apology. She looked at me stunned and, on realising that I was absolutely serious, told me to make myself scarce. I was furious with him and her.

      I asked many questions on my first ward and my first ward report reflected what they thought of me – a thorn in their side. On receiving my report, my Sister told me that “the trouble with you is that you cannot take criticism”. I clearly remember saying, “on the contrary, Sister, I take constructive feedback very well because that is how I learn” and I was about to say something about criticism but she cut me off with “there you are, that’s exactly what I mean”. She told me that I would have to change my attitude if I was going to be a good nurse. I was 18 years old and decided that I would definitely not be like her when I became a ward Sister.

      When I did become a Sister, I remember challenging a general surgeon on numerous occasions when he made questionable decisions on operations that he or his Senior House Officer intended to perform on our patients on the ward. The purpose of the challenge was always to ask him to re-consider and change his decision to one that would serve the patients’ best interest and he always did. He never liked my questions because they required him to question his own motives. However, my mission was to always act as patient advocate and not smooth his ego. I never pretended that I knew his job better than he knew his own. I am a nurse and was using my own knowledge to ask the questions. He did tell me 7 months after I had been there that I had improved the nursing care on the ward by 100%, but that he found me very difficult to work with. I acknowledged this fact and replied that my job was to improve the nursing care on the ward.

      The reason he found me difficult was because I was DIFFERENT. I would not make him tea or buy him biscuits after the ward round, as my predecessor had done (this was in the latter half of the 1980s). I did not always attend the ward rounds, but supported the Staff Nurses to do this, especially if I had been away or had days off immediately prior to the round. He did not like this at all. I questioned his rationale for doing operations as a general surgeon which, I knew – and so did he – should be referred to a specialist. As a patient advocate, I couldn’t stand by and let things go ahead without doing my best to change his decision. In short, I was a professional nurse with a clear sense of my own knowledge and skills, mindful that what the medics offer to patients is different to what nurses offer, respectful of both professions as equal and distinct.

      Knowing what and how to ask the questions and be listened to is what is needed to influence behaviour change. Being very clear about why you are asking the questions is very important. Who benefits?

      As a nurse, student or otherwise, you are a patient advocate. If you know that you have knowledge that is not being used, you must find a way of asking the questions in a way that will be listened to rather than ignored. I understand that this can be daunting. However, we are all equal at the end of the day – people with different jobs and different knowledge. Never forget that it is the patient whom we serve. Respect yourself and be true to your values. Don’t be put down or lose heart.

      • Thank you for giving some real, lived examples of how to question and what the consequences might be. Not quite what you meant perhaps, but your sentence ‘If you know that you have knowledge that is not being used, you must find a way of asking the questions in a way that will be listened to rather than ignored’ could be about me and my blog. I had all this questioning stuff inside me, that wasn’t being used, and I had to find a way of getting it out. I’m very pleased with the result.

  5. EmmaLu permalink

    I am a first year childrens nurse and a caremaker. I joined the caremaker scheme due to seeing bad practice as a patient and as a student. I have questioned practice many times in both settings. Sometimes I have been listened to others I havent.

    Fortunately on placement I have been lucky enough to work with mentors and staff that were willing to hear my point of view and take this on board. Im aware not everyone has been this lucky and there could be a time in the future when I am not so lucky.

    I also agree that courage and communication are a huge obstacle when you are trying to discuss potentially delicate issues regarding bad practice and maybe we need some input here. For me the fact that the patient could be harmed gives me that courage, im also quite a confident person and will stand up and speak out.
    For now I will continue to promote the 6cs in everything I do.

  6. @NurseVink permalink

    Hi EmmaLu! Great that you joined the conversation. And great to see that you continue to promote the 6Cs in all you do. Can you explain a bit more about how you promote the 6Cs? I mean, beyond obviously applying them to your own personal work (i.e. treating your own patients with compassion etc). How do you promote the 6Cs actively among your colleagues? Do you talk to them about them and their importance? Do you actively link some of the things you do to the 6Cs so people can see the direct impact of adhering to 6Cs on their own practice (and thus learn from you?)

    I am genuinely interested in how to not spread the word about the 6Cs to other people but how to get other people to actually improve their practice by being more aware of the 6Cs in their own actions.

    • @NurseVink permalink

      That should of course say: how to not ONLY spread the word….

  7. I think there is a lot care makers can do. I think this is not answered however by the care maker initiative as stands. Raising money for charity is awesome but that should be about promoting the charity not the care makers – IMHO the Caremaker name should have been in the background. The stuff I have seen has not been representative of that, however that does not take away from the utmost respect for raising money for Charity. I do believe there is much more support needed and maybe coverage of actual actions rather than promotions, and then there may be a better understanding of what care makers do as a minimum training for the role – after all what is a job without a job description? I don’t expect to be spoon fed but let’s face it, support should be forthcoming as should examples of evidence based changes. I no longer have time in my diary for it as it stands but still will promote the role as it is, not as I expected. To those who may find the role as it is is enough, it’s just not for me. As for using the 6Cs – damn right! But – know what they mean to you.
    People just reeling them off – sadly it feels like a tag line which is a real shame. I would really love to hear from Caremakers who have done something that has made a difference to nurses on the ground 🙂 Question is would Stop The Pressure and other such events been done without the Caremakers? My belief is with the passion of the students involved – yes! What does Caremakers offer for nurses on the ground facing things we cannot possibly factor in without lived experience on the wards
    as student nurses? x I would happily put back on my hoodie if that could be answered

    • @NurseVink permalink

      Thank you for this. I agree with everything you say. The things that are done by students and other people who are also Care Makers are great but they do not seem to specifically match up with what I thought Care Makers were supposed to achieve. They would probably have been done regardless of Care Maker.

  8. Thanks to everyone who read the posts and contributed to the debate, both here and on Twitter. My personal view (and I would stress that it is personal, and not necessarily shared by any other contributor here) is that nurses cannot be supported by a scheme sponsored by a government that does not support nurses. This is a government that won’t give nurses a pay rise because it is on an ideologically-driven mission is to make NHS pay structures more attractive to potential private contractors. This is a government whose Secretary of State for Health is happy to repeatedly blame NHS problems on some fictitious ‘lack of compassion’ amongst an occupational group it perceives as weak and unlikely to fight back, as a way of diverting attention from other groups whose alienation it sees as more risky. Is it plausible that a government with this agenda really wants to support nurses? I invite you to draw your own conclusions.

    • It’s Sunday afternoon, I’m knackered after a weekend of kiddy activities and think I’d prefer to have this conversation in the pub over a few.
      I know the government does not support nurses, teachers or any other public sector workers. Why would they? They don’t use those services.
      I get the political agenda, but the fact remains for whatever reason, some health care workers are not caring. I just want to be part of the lot, that despite the crap, wants to focus on connecting with human need. Not saying anybody else who’s not going for the care maker thing doesn’t. I need every bit of positive stuff I can get.

  9. Thanks for commenting. I’m not much of a drinker myself, so I’ll have to respectfully decline the offer of a few in the pub! I don’t know the figures on Coalition government members’ use of public services. The point is that although some of them may choose to go private for things like health care and education, for re-election they rely on the votes of people who have no choice but to use public services, and also those who work in them – including nurses. The vision for the NHS that the present government is putting before the public is one of greater private sector involvement, and as I have argued elsewhere, the push to hold down and then reform nurses’ pay is undoubtedly connected to this. 6Cs may also have a role to play in making nursing appear more ‘corporate’. As long as you agree with current policy, being an ambassador for the 6Cs presents you with no problems.
    I was truly appalled by the experiences you had on placement (recounted in Kateparsnip’s first comment above, for anyone who missed them) but I don’t think initiatives like Caremakers and 6Cs were really designed to address problems this serious. When it’s as bad as you describe, you need deeper sociological and economic analysis to explain it. And that’s my problem with Caremakers really – it’s well-intentioned, but it’s too simple. It doesn’t do the difficult stuff. For you, it seems to have acted in something of a support-group capacity – which is great – but the kind of help you needed is not something that should be left to an ad-hoc bunch of enthusiasts. Proper channels (eg from your university) should be in place.
    I do hope things improve for you and you find yourself some positive role models. In spite of everything, there are still plenty out there.

    • I was referring to being better at conversation than blogging rather than a literal invitation!
      Your comments and some of your other opinions on here are thought provoking. But am I right in thinking that you think if I sign on to go for the 6 Cs I’m not questioning current policy or the present government’s vision for the NHS?

      My own experience is that after an appalling placement experience, I was fortunate to get support from a network, one of which was the Care makers. It ‘simply’ gave soft support to enable me to do the difficult stuff of raising concerns, attending safe guarding meetings etc. I’m not expecting it to save the NHS all on it’s own.

      I’m not sure what you mean by, ‘I hope things improve for you and you find yourself some positive role models’?? The poor practice and lack of mentorship occurred last year. I can learn from how I don’t want to practice as well as positive role models.

      Interesting to read differing opinions and I acknowledge the importance of continuing to challenge ideas and practices in all areas, especially as my first year nurse training has been more about jumping through hoops.

  10. In my clumsy and plainly ineffective way, I’m trying to empathise. I’m sorry if that’s unwelcome. I think it is fair to speculate how the Caremakers initiative may fit in with other government policy – especially as politics is a subject that Caremakers itself seems to be at pains to avoid. I think it is perfectly reasonable to present a view which others may not have thought of or may not have felt able to articulate. If you don’t agree with me, that’s fine – make your case and we’ll have a debate. As with so many other controversial areas in life, the important thing is that you have thought about it, not simply gone along with it without thinking; and it appears you have thought about it. Your personal political allegiances – like those of any other private citizen – are none of my business.

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