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Learning to Swim

March 10, 2015

A guest blog by @_madewithcare

What place do student nurses have in criticising and quality improvement? I ask this because I’m a student nurse myself and I’m having what will no doubt be one of many moments of cognitive dissonance between idealism and potential consequences out in the real world.

A little background might be useful. I come to nursing by a circuitous path which meant before I started working as a healthcare assistant I walked briefly in the adversarial realm of lawyering. To me, confrontational discussion (with all necessary civility) is a means to an end, parties hacking away at either side of an argument to ultimately reveal whatever core of truth there is to be found. I’m reasonably happy to accept criticism even when it comes with insults; I think the content of a message is more important than the form and that rudeness doesn’t negate a point by itself. Don’t get me wrong: I value politeness greatly. I’m just ready to give others a pass if they’ve got a point. Ben Goldacre has described Q&As at medical academic conferences as “some kind of bloodbath, people tear strips off each other and that’s not a bad thing… it’s like some sort of consensual intellectual S&M. We love it, it’s what we want, it’s good for us!” Unrestrained discussions are necessary when you’re dealing with issues that might cause unimaginable suffering if you were to get it wrong. It’s a nice thought that we might be able to put ego aside in order to get things right. Isn’t it?

Student nurses are actively encouraged from many quarters to go forward and challenge (in the right way) and not be shy about having an opinion. We had a member of staff introduced to us whose job is officially to handle whistleblowing concerns from students on placement and she was adamant about encouraging us to speak up. Ambassadorial programs like the Care Makers and SQA Project revolve around advocacy for improvement and embodying the Courage (hngh) necessary to drive that forward. The Nursing Times piece on the student-only #FutureMHN Conference recently led with: “Mental health student nurses have been urged by leading academics and nurses to challenge conventional practice and take the lead in future research to develop new models of care and treatment.” We’re the future of the profession. We’re important. So we’re told…

Recently I met with some of my lecturers to talk about my goals for the coming year and naturally some of these were suggestions where I thought there might be room for improvement, or questions that ought to be asked. Without going into details, some of it runs the risk of making myself unpopular; as much as you might try for a positive framing of “this could be better”, a person can hear the negative “this isn’t good enough”. So in the conversations I had, firstly with a faculty member of international renown, and then with a Care Maker who’s subscribed to the School for Health and Care Radicals, what they stressed to me was that I should maybe take a few breaths and seriously consider calming it down a touch. That perhaps now, as a fledgling undergraduate, was more a time for listening than trying to take on the world. I’m paraphrasing but that’s what I understood from it, and let me be clear both of these people are immensely respectable and whatever advice they kindly share is worthy of serious contemplation. That’s left me with some extensive rethinking to do and I honestly find myself a little lost, in need of the wisdom of experience I don’t have. Fortunately, others have shared their own experiences.

@NurseVink previously wrote on the perils of being too enthusiastic on placement, being nicknamed “Spaniel” and, for the crime of volunteering some useful information, being 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” . She describes being a Care Maker as of no help to her in navigating that situation. Reality 1, Idealism 0.

Michelle, another Care Maker, describes experience of placement mentors: “We’ve all had our share of amazing mentors and some more ‘iffy’. When you are unfortunate enough to have a less than enthusiastic mentor you are encouraged to ‘learn from the experience’, ensure that you don’t become one of the disaffected nurses when you qualify and really just get on with it. Is this the right approach? I’m not so sure that it should be acceptable.”

Rebecca Kidman, a Nursing Times Student Editor, writes about the fear of developing a reputation: “I have heard of incidences where a student has whistleblown and can’t get work when qualified within that area. I am fearful of the repercussions of even writing that last statement because of the impact it could have for me. There is the risk of being viewed as a troublemaker and worries about failing the placement or not getting paperwork signed off.”

Toys, Tears and TPN relates the lasting consequences of getting on the wrong side of staff: “The issues I took last year, and still take, is about the horrendous way in which I was sat down and systematically torn apart by a member of staff I’d spoken to no more than two or three times in the space of 12 weeks. […] what burns even more is the complete and utter confusion and sense of betrayal, even. Again, typing that out I question myself – do I really feel this way still? Why am I so bitter?”

I remember reading in astonishment another student blog about the negative feedback at the end of placement: “According to my mentor, I ‘learn too fast’ and ‘pick things up very quickly’ and I need to be careful of this in future placements as some mentors don’t like a student that thinks they know everything. […] now I am feeling doubtful about the level that I apply myself at as ‘I am only a first year’.”

And so on and so forth. The warnings are there for the heeding. The popular phrasing at the minute seems to be to rock the boat without falling in. Now I dislike analogies but if we go with that, it sounds rather more like you need to be wary of people trying to push you out of the boat than of losing balance yourself. It would seem odd then not to shove back, but certainly the power imbalance between professionals and students makes that unwise. Sir Robert Francis recently discovered many tales of students apparently dropping in performance over a single placement they’d raised concerns at and it’s not hard to see the wide potential for abuse in the NMC “good character” test students must pass for their PIN. The School for Health and Care Radicals suggests “rolling with resistance” as the way forward, but honestly I struggle to see myself embracing that fully. Following the astute warnings from my lecturers, I’ve had a good hard think about who my heroes are, who I aspire to be like, and that turns out to be people like Ben Goldacre (spent, with the Guardian, £535,000 defending a libel suit, has been followed and received violent threats), Edzard Ernst (forced into early retirement for disproving quack remedies), Simon Singh (£200,000 on libel costs, ultimately winning legislative reform because he didn’t stop fighting) and others similarly, self-destructively outspoken. Clearly, I don’t have the resources, both personal and financial, to spend on winning those sorts of battles any time soon.

So one day, but not today. Right…? I’d love to know how others see students’ role here, in the cold light of the real world where a misstep could conceivably be career ending. Keep your head down, or peer over the parapet into the face of danger? Are students too vulnerable to meet the ideals we set?

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6 Comments
  1. Hi @_madewithcare, cracking blog post in which you get to the heart of the problem as I see it, so many of the glut of NHS initiatives are in danger of being used to control people, to stifle candour and to create people who ‘challenge’ in a certain (easy to be controlled) way. I blogged about this last week http://www.georgejulian.co.uk/2015/03/04/group-mentality-and-the-nhschangeday-mafia/ and on a couple of occasions last year https://georgeblogs.wordpress.com/2014/11/05/whos-edge-counts-theedgenhs/ and https://georgeblogs.wordpress.com/2014/09/20/courageous-challenge-versus-conformist-control/ and https://georgeblogs.wordpress.com/2014/10/08/4-more-cs-callous-cruel-calculating-and-cowardly-6cs-justiceforlb/.

    For what it’s worth your post gave me hope, that you were considering challenging the status quo, speaking up and doing the right thing. I hope that you feel able to do so, not to sit gently rolling with the boat, but to jump out of it and swim with the many patients, carers and grieving relatives that have no luxury of a boat in the first place. The more student nurses that jump over board the more those left sat on it may feel the urge to actually throw a life raft or consider whether they’re sailing in the right direction at all. (I’m struggling with this metaphor now so forgive me). I think it’s essential that you speak up if you feel something is wrong/dangerous/outdated, even with all the risks associated with it. Some will no doubt view me as naive for suggesting that, but as someone who was warned off campaigning (with #JusticeforLB) for the potential damage it would do to my business, I can honestly say I don’t regret it at all. To borrow a Maggie Kuhn phrase, I think we must all ‘Speak your mind even if your voice shakes’. Thanks for posting and good luck with your studies and future, I think the NHS will be lucky to have you.

    • Thanks for your comments and kind words, I read your blog with interest. I’m not sure I have it in me to not make something of it when I see patients potentially endangered, but every time I raise something, it feels risky and deeply unpleasant. So far I’m lucky to have had a welcoming reaction and things got fixed, fingers crossed that continues! Where it directly affects patients I don’t see myself as having much of a choice, but beyond that I think I’ll be treading quite carefully for a while.

  2. Dear madewith.care,

    I loved your blog and I’m sorry that you have met with some discouragement from those you hoped would be more ‘up for it’. Don’t let that stop you – don’t leave it until you are old enough to have nothing left to lose before you say the things that need saying.

    If you’re getting a good education from your university programme then you should speak and challenge with confidence. Be direct (but that’s not the same as rude). Rudeness takes the edge off your opinion – even when you are absolutely right. Sad, but true.

    So keep on keeping on, be direct, be open and don’t let the system scare you.Some you’ll win and some you’ll lose, but if you’re well informed, direct, acknowledge when you get it wrong, then you’ll gain more respect than dismissal.

    all the best

    June

    • Thanks for commenting and your encouragement June. I wouldn’t call it discouragement as such, I think it was more about choosing which battles to fight. I know I can come across as a bit prickly in person if I’m not careful, so it’s not an unfair warning. I’m so glad you mentioned gaining respect, that’s such an important resource and I’m working hard to establish myself as credible. I think raising concerns at work where people know and (I hope) trust me has shown me it’s valued when done in that context.

  3. Steve Bradley permalink

    ‘Speak the truth until your voice shakes’. By all means speak… and shake if you have to… but it doesn’t mean you are right, or that you are speaking the truth.

    To see ‘confrontation’ as the path to enlightenment and progress, is more or less to affirm the twisted ‘status-quo’ in health care as it is. Ben Goldacre is quite wrong on the value of a bear pit culture. Personally, I’ve sat at too many MDT’s, amidst the alpha-males and females, whispering to myself, “there’s got to be something better than this… aaargh!”. I’ve heard a surgeon shout at an oncologists, “what you do is a load of crap!” (and seen behaviour that is much worse elsewhere in the NHS). I’m sorry Ben, we don’t all love it. Not everyone digs the S&M stuff. It’s not an example to be emulated by students, or anyone else. It impedes good care and obstructs forward movement. It’s a system in which the loudest and rudest sometimes call the shots. The rest of us just want to go to work, apply our hard-won skills and knowledge for the benefit of others. We want to progress the sum of knowledge by participating in research, acting collaboratively with our team-mates and treating each other as grown-ups. Student nurses too want to be treated as grown-ups. However, just occasionally they arrive on our units pumped up and infused by an embryonic and ideological desire to hear their voices ‘shake’. Some talk so loudly and metaphorically shake so violently they can’t hear or don’t want to hear what we are saying to them. I say some, not the majority. They are taught to mistrust us. For some, their pupils are already fixed on some distant upland beyond the point of qualification. I repeat, ‘some’, not the majority. Calmly and politely (ideally) we remind them that though their voices are heard, they first need to earn the right to shake the tree. And shake the tree they most certainly will, provided we do our jobs properly, are open to sensible debate and encourage the best from and for them.

    Reading various forums and blogs from academics and students I’m getting rather tired of the continual ‘nursing is broken, get out there and challenge everything’ refrain. It was the bread and butter of lectures and essays when I did my ‘training’ in the late 1990’s and continues to be an unhealthy preoccupation of academics today, many of whom left the profession many years ago. It pissed me off back then that nursing profession was constantly self-harming in this way. It’s a false picture and doesn’t reflect reality. It certainly doesn’t reflect my experience as a nurse over 10 years, or as a patient in recent times. Blaming and shaming nursing practice is a huge diversion which obscures the true crisis which is a systemic one of chronic under staffing, underfunding, short-term thinking, a deep rooted culture of bullying, favoritism and exclusion, and a political elite that continually rob us of the oxygen we need to offer professional care with a compassionate face. You’d be forgiven at times for thinking that universities are unconsciously complicit in this shaming of the nursing profession. In effect, they are doing the government’s dirty work for them. I’m reminded of Chomsky’s dictum that if you want to privatise something: bad-mouth it, demean it, run it down in the public’s eyes, then you can sell it… pay them less…maximise profit! It seems that a few steadily diminishing concerns regarding actual nursing practice over recent years have morphed into a much nastier political agenda

    One last thing, I too was also in the law before entering nursing. The idea of lawyers simply hacking away at each others arguments to reveal the ‘truth’, seems to me to a bit simplistic. It certainly can get rowdy in some of the lower courts at times, but in general law is a far more subtle, respectful and reasoned business than healthcare. So much so, an outside observer looking in would be easily bored at the spectacle. Counsel present their arguments to judges, not to each other. In the higher courts they debate points of law, they don’t confront or tear apart. It’s not about them. Judges will dissent from each other as to what is the ‘truth’ in particular cases. These ‘truths’ change and evolve greatly over time. The ‘truth’ at any one point in time can be abolished by governments, through legislation, to suit their own political interests. ‘Truth’, replaced by a new ‘truth’. In this sense ‘truth’ is a fluid concept. It’s a bit like the ‘evidence’ student nurses are taught to seek out and chant as a never-ending-mantra. What exactly is ‘truth’ and what is ‘evidence’? Are there any teachers encouraging their students to ask that question? Logic and thoroughness demand that students should place their teachers under as much suspicion as their practice mentors.

    In comparison to a student nurse, as a student lawyer, I did not have the automatic right of audience (as a legal representative) in any court. I had to study hard, qualify and then build up a basic reputation to progress and be allowed the opportunity to practice law… to be heard. Up until that point, it was more my role to build up my knowledge base, make a good fist of the bits and pieces I was offered, and in turn inspire confidence in others that they should instruct me to represent them. To respect my peers, be challenged and find the answers to questions, rather than blindly challenge and confront. To have adopted the latter approach would have been professional suicide. Having been suitably challenged, I was then well placed to reason, argue and challenge on behalf of others. Ultimately, it turned out to be much harder than I thought to get a lasting foot in, so I became a nurse. Perhaps student nurses could take a leaf out the lawyers training manual. It’s not all about you.

    • Hi Steve, thanks for commenting. I definitely agree that the competitive medical culture has its limits and it’d be for the best if we could all just agree and get along in a collegiate fashion without being abusive to each other. I’m not so sure I agree that it impedes forward progress, not a perfect example but compare the ineffectively gentle, wide agreement of the Ethical Standards in Health and Life Sciences Group to AllTrials’ genuine progress (http://www.bmj.com/content/347/bmj.f6062). And it’s not like AllTrials is particularly militant, just a bit more direct about pointing out problems and who’s responsible. I’d hope there’s room for both styles, where they’re suited.
      On blaming and shaming nurse practice as a diversion, I’m very much with you there, although I feel like I’ve noticed less of that in the media recently with increasing distance from the Francis Report. It did make me sad as an HCA to have two brilliant student nurses with us on their first placement, who reported they’d been told to expect all sorts of nightmarish behaviour out in practice, which obviously didn’t come to pass as they found people going about things in a professional and proper manner. There were a bit perplexed about why they’d been briefed in that way.
      You’re absolutely right of course about courtroom antics being nothing like how people expect from overblown TV dramas. I guess the point to take from that is the court system is set up and regulated to be *fairly* adversarial and everyone there is consenting, where in a healthcare setting it’d be up to individuals to informally agree to behave properly, towards a common purpose. Maybe it is naive to think that can happen, I guess I’ll find out with more experience? As for if we’re taught about the meaning of truth and evidence, for what it’s worth I was reading this in Nursing Philosophy just the other day: http://onlinelibrary.wiley.com/doi/10.1111/nup.12077/full

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