How do nurses cope when values and practice conflict?
How do mental health nurses respond when their values conflict with their practice?
In this article…
- Development of professional ideals in mental health nurses
- The effect of conflict between ideals and organisational constraints
- Nurses’ strategies for responding to these conflicts
Gemma Stacey is a lecturer in mental health; Kirsty Johnston is a research associate;Theo Stickley is associate professor, all at University of Nottingham, division of nursing, Nottingham; Bob Diamond is a clinical psychologist, Nottinghamshire Mental Health Trust.
Stacey G et al (2010) How do nurses cope when values and practice conflict? Nursing Times; 107: 5, early online publication.
Background A lack of opportunity to express values in nursing practice and a conflict of ideals with organisational constraints are associated with low job satisfaction and high attrition rates.
Aim To explore the stories of mental health nurses in inpatient settings to find how values influence their experience of nursing practice.
Method Twelve participants, who had between six months and three years’ experience of post-registration practice, were interviewed using a narrative research method.
Results The findings support the literature relating to professional socialisation, which acknowledges that nurses’ values are often established before they start training. Participants described values that were consistent with a commitment to person-centred nursing care and professional and ethical principles expected by external governing bodies.
Conclusion Mental health nurses are aware of the dissonance that arises when there is a conflict between their values and their practice. They respond to this in a variety of ways, notably through acceptance, rejection or innovation.
Key words: Socialisation, Mental health nurses, Professional values
- This article has been double-blind peer reviewed
5 key points
1. The values nurses hold when they enter the profession remain intact
2. Workplace constraints and resistance may prevent nurses from applying these values
3. Having to cope with conflict over values may affect capacity to work with people in distress
4. Strategies to cope include acceptance, rejection and innovation
5. Conflict over values could explain the high levels of stress and attrition in mental health nursing
Values have a major influence on the actions of practitioners and are integral to socialisation and the consequent development of professional identity (Woodbridge and Fulford, 2005; Fagermoen, 1997). It is unsurprising, therefore, that the significance and role of values in mental health practice has gained momentum in UK policy (Department of Health, 2006a; 2004). However, a lack of opportunity to express values in nursing practice and a conflict between values and organisational constraints have been strongly associated with low job satisfaction and high attrition rates (Forsyth and McKenzie, 2006; Takase et al, 2006). While there has been much commentary on the low morale and disillusionment of the nursing workforce in general (DH, 2004), there is less on mental health nursing.
This study was undertaken to improve understanding of why this issue by exploring nurses’ stories about meaningful events early on in their practice.
Nurses often experience conflict between the values they hold and develop during their education and their ability to apply them in the workplace (Kelly, 1998). Instrumental to this is the process of professional socialisation.
Davis (1975) proposed a model known as “doctrinal conversion”. This has been frequently criticised as it does not adequately recognise the influence of the values and assumptions about the profession held by students when they start training (Fitzpatrick et al, 1996; Du Toit, 1995).
However, part of Davis’ model is generally accepted. This involves nurses internalising the values, norms and expectations of the profession.
Simpson and Back (1979) suggested that socialisation has three stages. It begins with pre-socialisation, where values are shaped by societal groups and public perceptions of nursing. This is followed by formal socialisation, where students learn to behave in an appropriate professional manner. The process is completed during post-socialisation, where the outcomes of formal socialisation are applied to practice.
Du Toit (1995) said that values change through the professional socialisation process. When these changes occur, individual’s idea of self also changes to such an extent that a “nursing identity” is developed as part of a collective..
Bradby (1990) maintained that, when student nurses qualify, they go through a process of change to move from having one social status to another. This process results in a “reality shock”, where they experience a loss of personal identity before making sense of the process some months later.
This early role conflict has been observed in some depth and it is acknowledged that the transition to qualified nurse is ill defined (Holland, 1999). The nurse’s sense of role identity is challenged by issues including a lack of support, poor nursing role models, time pressure, role constraints, staff shortages and work overload (Maben et al, 2006).
Kelly (1998) identified the importance of “preserving moral integrity” as the basic psychosocial process when newly qualified nurses adapt to the “real world” of work. Kelly suggested that, if newly qualified nurses believed they were not living up to their moral convictions, this could lead to moral distress and self blame. Here, they become aware of the discrepancy between their perception of what constitutes good nursing and what they observe in practice, and they cope with this by redefining their perceptions of their role.
Several studies recognise the danger of newly qualified nurses becoming desensitised to poor nursing practice habits and adopting them as their own (Mackintosh, 2006; Holland, 1999). It has been suggested that this can lead to a willingness among students to shift their self-identity to justify the loss of ideas and become proficient in their new role( Mackintosh, 2006).
Jowett et al (1991) warned that that newly qualified nurses may lose their skills as “knowledgeable doers” and “confident analytical thinkers”, as they become socialised into a culture where routine and task-based work approaches are valued.
The study took a narrative approach to identify the influence of values on mental health nurses’ experiences of their practice. Denzin (1989) described a narrative as a story that tells a sequence of events. These events are significant to both the narrator and audience.
Narrative inquiry is a research method used to understand how people think through events and what they value. It looks closely at the story constructed by the storyteller, and the information and meaning it portrays (Chase, 2005).
Ricoeur (1984) suggested that stories have an inherent morality. Asking nurses for stories about their practice is therefore important – their choice of stories provides a way to disclose embedded meanings and values that reflect what they want to convey about themselves as professionals.
During one-to-one interviews, participants were asked to tell stories of events that were meaningful to them in their work as mental health nurses. The interviews were unstructured and designed to encourage storytelling. This allowed participants to give free responses and encouraged them to explore in detail their personal experiences and perspectives.
The NHS National Research and Ethics Service granted ethical approval to conduct the research and all participants gave written informed consent. Nurses were assured of anonymity – the names in this article are pseudonyms.
We employed a purposive sampling technique, which involved distributing a letter via clinical team leaders that invited all mental health nurses with between six months’ and three years’ experience in adult mental health inpatient settings to participate. This criterion was used as evidence suggests that nurses’ early career experiences are highly influential in socialising. Twelve participants agreed to take part.
The data analysis began with reading and re-reading the verbatim transcripts of the interviews. Value-based event narratives were then extracted from the transcripts. In these extracts, the nurse described where the event took place and the context, explained the actions and interactions that took place, and evaluated or concluded the story. A value-based event narrative was identified if it related to any expression of a value as defined by Fagermoen (1997) (Table 1).
We conducted a thematic analysis of these extracts that identified common areas. This was carried out independently by two members of the research team then validated through collaborative discussions with a multidisciplinary group of mental health professionals and academics.
The group collated the common themes into three main areas:
- Values embedded in practice;
- Dilemmas and conflict of values in practice;
- Coping with conflict - within this theme, three types of stories were identified and named: acceptance; rejection; and innovation.
Values embedded in practice
The findings consistently showed that the values of newly qualified nurses were formed before they started their training. These were reinforced in practice through their admiration of inspirational role models or their criticism of observed practice that they did not respect.
The values expressed corresponded with those described by Fagermoen (1997). This included a person-centred approach that emphasised the importance of the therapeutic relationship, working towards each client’s goals and improving services for their benefit.
One participant, Florence, noted: “My job was to work with people… it was all about supporting people and relationships.”
Professional values determined by external governing bodies, management and colleagues were expressed at least once by eight participants These related to external self oriented values associated with professionalism. Participants did not identify these values as external but rather considered them as their own.
Alice said: “[It’s about] being able to justify what you’re doing, how to give out meds, how to do injections, how to do a care plan and a risk assessment, and all of those things which you have to take responsibility for as a qualified nurse.”
Dilemmas and conflicts of values in practice
Participants described a range of organisational constraints that they felt restricted the expression of their values in practice.
Lack of resources was reported as an obstacle in 11 of the participants’ value based event narratives.
Ben said: “I think that it’s a culture from the workforce… we’ve had problems and it’s to do with resources.”
The conflict between promoting client choice while being restricted by an organisational reluctance to take risks was mentioned in seven participants’ narratives. This appeared to be when self-oriented values conflicted with the other oriented values – for example, professional regulations were viewed as restricting service users’ rights to autonomy.
As Chris said: “Supposing you’re dealing with a service user who does have a particular risk history… sometimes, you need the go ahead to just simply try out something like an interview, like getting on a bus, learning how to do all those things that can get a person to an interview, to a job, to a sense of self esteem, without being impaired in any way. But I meet too much institutionalism.”
Six participants spoke of low motivation among staff. Colleagues were resistant to participants’ attempts to change and improve practice, which restricted their values of creativity and independence.
Adam commented: “You’re always mindful that… they’re thinking, ‘just a minute, I’ve been doing this for the last 25 years and who the hell are you?’.”
Of these six participants, four spoke of feeling unsupported in their new roles and described how this affected them emotionally to such an extent that they sometimes questioned their view of their role as a nurse.
Veronica said: “I kind of remember going home, just thinking, ‘is it really worth it?’ I don’t think anyone should be exposed to those sorts of things – I did question what I was doing.”
Coping with conflict
Participants appeared to cope with the conflict they experienced in a variety of ways. The findings illustrated three types of stories that related to coping strategies.
Participants did not consistently adopt one of the following coping strategies, but adapted their response depending on the specific event.
All participants acknowledged that their values were challenged at times, but had chosen not to raise this in practice. In these cases, they accepted they would continue to work within the constraints, despite the personal conflict they were experiencing.
James noted: “There’s nothing much I can do if that’s the decision to be made. At the moment, you have to go with it and you have to do it. In here, you’re thinking it’s wrong, you can argue that you think it’s wrong, but you don’t seem to get anywhere.”
On other occasions, four participants strongly questioned the organisational philosophy and the limitation this placed on expressing their values in practice. The personal difficulty this conflict produced appeared to result in them considering leaving their job and working elsewhere.
Hazel said: “I will probably just end up feeling like leaving… because I think I can’t cope with that stress, or I end up thinking I can’t follow this through so I can’t promise this to this client. And I can’t continue to do it.”
Seven participants had worked within the system to initiate change, despite resistance from others and potential separation and hostility from the team. Four of these had been promoted at an early stage in their career.
Leila noted: “Probably having a bit of a rebellious streak helps, [as does] challenging some of their preconceived beliefs about what’s the best way to nurse people with mental health problems, but also, having, hopefully, having sensitivity not to make people defensive… where people don’t really want to listen and you. But also, a passion for making sure that people don’t feel disrespected, whether it’s staff or residents - and I’ve still got that passion.”
The narratives told in this study support the literature, which suggests that student nurses enter education with person-centred values already clearly established (Fitzpatrick et al, 1996; Du Toit, 1995; Simpson and Back, 1979). They focused on the importance of caring, relationships and altruism, as identified by Fagermoen (1997). The participants’ values were reinforced by positive role models, who they perceived to be good nurses.
However, participants did not internalise nursing practice that did not reflect their values in a similar way. Instead, they recognised it as conflicting with their own values, and reinforced their belief in their own view of good nursing practice. This contradicts research by Mackintosh (2006), who found that the maintenance of caring values only occurred in the minority of cases.
The person-centred values identified in participants’ stories were accompanied by the expression of values associated with professional responsibility and organisational expectations. These findings echoed those of Woodard-Leners et al (2006), who identified clusters of nursing values that related not only to the person-centred aspects of nursing but also to accountability and responsibility for practice, competence in practice and legal issues.
A large proportion of the participants’ stories were about the conflict they experienced and the barriers that prevented them from applying their person-centred values in practice. Stories included the impact of limited resources on nurses’ ability to apply these values on a one-to-one basis with service users. The participants’ frustrations appeared to reduce job satisfaction.
Supporting this, Robinson et al (2005) found that burnout and attrition in mental health nursing were related to a lack of contact and positive interaction with patients, while Takase et al (2006) suggested mental health workforce job satisfaction was positively related to care-giving opportunities. This suggests that, where the ideals of nursing practice are not upheld in reality, nurses are less satisfied with their experiences.
Further conflicts identified in participants’ stories related to the resistant attitudes directed at them from some members of staff. It is acknowledged that nurses are a disempowered group, within both medicine and the professional arena as a whole (Matheson and Bobay, 2007). Freire (1970) suggested a consequence of this was “horizontal violence”, whereby the powerlessness nurses experienced led to them directing their anger and hostility towards each other.
Participants’ stories emphasised a need for support from colleagues and other professionals. The conflicts they described suggested this was not necessarily occurring in practice. Although person-centred values were emphasised in relation to working with service users, it appeared that the nurses did not always demonstrate that they valued each other.
The recognition for the psychological needs of mental health workers to be met has been acknowledged (Gray et al 2005; Sainsbury Centre for Mental Health, 2006). As Maslow (1954) suggested, if individual safety and wellbeing needs are not met, it becomes difficult if not impossible for a person to achieve fulfilment and success. The implication of this for nurses whose own basic needs are neglected may be that they feel less able to provide support to others.
Stories relating to how participants dealt with the conflict they experienced revealed that they varied in how they responded. Responses were classified into three categories: acceptance; rejection; and innovation.
Participants appeared to justify their acceptance by regarding their powerlessness as an inevitable consequence of their position within the system.
On the surface, these accounts may seem to support the literature regarding conformity in nursing socialisation. However, the nurses were acutely aware of this dissonance and did not appear to adopt these conflicting values as their own. It is possible the strain of working with this dissonance could make future burnout, disillusionment and horizontal violence more likely, as Forsyth and McKenzie (2006) suggested.
Participants who told stories of rejection were considering whether conflicts would lead them to compromise their values to a degree that was unacceptable to them. This could, on one level, relate to the experience of reality shock identified by Bradby (1990) or the self-criticism recognised by Kelly (1998), resulting from individuals’ perception that they were not living up to their moral convictions.
Resolution of conflict was told through stories of innovation. Here, participants viewed themselves as having the personal autonomy to take control of their practice, working creatively within constraints and conflict to foster change. This supports Clouder’s (2003) assertion that nurses are not necessarily passive accepters of change. The concern expressed by Jowett el al (1991) that newly qualified nurses may lose their skills as knowledgeable doers and confident analytical thinkers was not upheld in these cases.
Those who innovated despite resistance showed high levels confidence in their practice. This is supported by Bradby (1990), who said that the reality shock on entering the profession has less influence on those with high self-esteem.
These findings are significant in light of the strategies to improve workforce retention featuring highly in mental health service policy (DH, 2006b). McKenna (2003) suggested employers should ensure that support services were readily available to all new graduates to prevent the possible detrimental psychological impact of horizontal violence. Primary prevention should begin with education and training to enable staff to cope with difficult working relationships.
From an educational perspective, the findings suggest the importance of raising the awareness of values and their role in influencing the experience of nursing practice. This should involve the discussion and questioning of values and could be guided by the work of Woodbridge and Fulford (2005).
Within practice, defined support strategies should be in place during the transition from student to practitioner; this supports the Nursing and Midwifery Council’s proposals for a mandatory preceptorship period.
We are planning a five-year longitudinal studythat aims to explore the consequences of coping with a conflict of values after registration.
Voluntary participation may have unintentionally led to a sample bias, as those who might have conformed and changed their values may not have wished to take part in the study. The experience of conflict may also have been too painful for some to share for the purpose of research.
The general nature of the question and the unstructured method of data collection meant that the values examined within the study were somewhat loosely defined.
We considered structuring the interviews to relate to a set of clearly defined nursing values, but felt that inclusion may have led to participants narrating stories they felt the researcher wished to hear, rather than those that were most relevant to them.
The findings of this study show the values held by the participants when entering the profession remained intact. However, the application of these values is tempered by confounding factors. The narratives from the study add to the professional socialisation literature by suggesting that nurses do not necessarily simply conform to social pressures, but respond in a variety of ways – accepting, rejecting or innovating. None of these responses involved the complete loss or alteration of their values.
However, the long-term implications of coping with conflict in this manner could explain the high levels of stress, burnout and attrition within the mental health nursing profession
Within mental health in particular, having to cope with conflict could affect a nurse’s capacity to work with people in emotional distress, as their own emotional needs are not being adequately met. The development of preventative support strategies in education and practice may go some way to counteracting these difficulties.
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