Identifying the mismatched views of student and qualified nurses on what nursing is and what students need to learn from their time on the ward
Helen Therese Allan, PhD, PGDE, BSc, RNT, RN, is senior research fellow and director; Pam A. Smith, PhD, MSc, BSc, RNT, RN, is GNC professor of nurse education; both at Centre for Research in Nursing and Midwifery Education, Faculty of Health and Medical Sciences, University of Surrey.
Allan HT, Smith PA (2009) How student nurses’ supernumerary status affects the way they think about nursing: a qualitative study. Nursing Times; 105: 43, early online publication.
Background: Supernumerary status fundamentally shifted the way the profession thought about student nurses’ clinical learning, but it has not been without its critics.
Aim: To examine how supernumerary status affects the way students think about nursing.
Results and discussion: We suggest there is an increased division of labour between registered and non-registered staff, so student nurses observe HCAs performing bedside care and RNs undertaking more technical tasks. This leads students to reject bedside care as part of nursing. Our data suggests that being associated with such work in their supervised practice may lead to students feeling stigmatised. This can then leave them feeling unprepared for their future role as trained nurses who do not have time to perform such tasks.
Conclusion:There is clearly a mismatch between qualified and student nurses’ views of what nursing is and what student nurses need to learn.
Keywords: Supernumerary status, Student nurses, Nurse education, Nurse training
- This article has been double-blind peer reviewed
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- Students need to feel part of a ward nursing team and a wider profession.
- They need to be included in the nursing work which qualified nurses perform.
- Students need to observe and participate in bedside care as well as more technical work, to learn how to supervise “care”.
- Bedside care, as well as the more technical aspects of nursing, can contribute to student nurse learning.
In this article, we use findings from a qualitative study of nurse education and training to assess how supernumerary status affects the way students think about nursing. It was prompted by Gordon Brown and David Cameron’s speeches to this year’s Royal College of Nursing Congress (Brown, 2009; Cameron, 2009). These speeches, and the report of the Commission on the Future of Nursing and Midwifery, due to be published early next year, show that nurse education remains a topical, political issue (Commission on the Future of Nursing and Midwifery, 2009).
Gordon Brown said nursing is a “profession where you work with your head, heart and hands at the same time”, as he argued that it should be able to develop and still remain a caring profession.
David Cameron said: “There’s no better way to learn about these things [nursing] than by putting down the textbook and getting practical training with living, breathing human beings. But too many of today’s placements don’t give student nurses the practical experience they need. They’re stuck in the role of observer, feeling more like a spare part than a helping hand. We’ve got to find a way to make training more practical…” In this statement, he implicitly criticised how student nurses learn in clinical areas today, that is, they no longer work as apprentices but undertake a supernumerary role.
We suggest that the consequences of introducing supernumerary status may have changed student nurses’ understanding of nursing. Gordon Brown’s aspiration that nurses think, feel and undertake practical work may no longer be a reality for students.
Cameron focused on the experience of being a student now that student nurses are no longer key to the NHS workforce. They are university students who work in clinical placements supernumerary to workforce numbers.
As a result of this, bedside or essential care has increasingly been devolved to HCAs who have, since the early 1990s, replaced the student apprenticeship workforce. This change in nursing education occurred as a result of the Project 2000 curriculum introduced in the late 1990s (NMC, 2004), the subsequent fitness for practice curriculum (UKCC, 1999), and at the same time as nurse education moved into higher education.
Supernumerary status means that student nurses are additional to the clinical workforce and undertake a placement in clinical practice to learn, not as members of staff (NMC, 2004). However, this does not mean that students do not work while on placement; they are expected to learn through supervised participation in clinical work (Arkell and Bayliss-Pratt, 2007). The level of supervision depends on the stage of training and previous experience; the role of the supervisor or mentor is crucial to learning (Donaldson and Carter, 2005; Spouse, 2001).
Supernumerary status in nursing education should have fundamentally changed student nurses’ role in clinical areas after it was introduced in the early 1990s. However, studies show it is not always a reality and the apprenticeship model still exists (Elcock et al, 2007). This may be because supernumerary status becomes difficult to sustain when mentors’ focus is on working rather than student learning, leading to arguments for improved clarity of their role (McGowan, 2006).
Attitudes to supernumerary status can be both positive and negative (O’Callaghan and Slevin, 2003). For example, supernumerary status is viewed negatively by mentors in clinical areas because of the associated increased workload, and positively because using students as co-workers enables the clinical team to get through the work (Hyde and Brady, 2002).
Negative attitudes to supernumerary status can also affect patient care, as Pearcey and Elliott (2004) found. A negative attitude to patients generally affected the ward learning culture and resulted in poor patient care and student learning.
Spouse (1998) gave a more positive view of supernumerary status in her discussion of ”legitimate peripheral participation” - the process by which student nurses are “allowed” to observe clinical care performed by others, either registered nurses or HCAs. Increasingly, because bedside care is delivered by HCAs, students observe HCAs delivering this care and registered nurses delivering drugs or other care where it is necessary to be an RN (Mackintosh, 2006). We argue elsewhere, in an unpublished report, that staff have clear expectations that students should learn through working, and that legitimate peripheral participation was not considered appropriate for student nurses in general, acute clinical areas. We note that McGowan (2006) and McCormack and Slater (2006) suggested that views about supernumerary status vary according to nursing specialism. For example, attitudes are positive among students and staff in intensive care.
Our study investigated how changes in nursing leadership roles have influenced how student nurses learn in practice settings in the NHS, given the move to higher education and other changes such as the introduction of supernumerary status and substitution of student nurses’ labour with that of HCAs.
The study was in two stages over two years and included:
- Consultation with stakeholders and a literature review to evaluate clinical learning and leadership in the NHS to produce an evidence-based conceptual framework to generate questions for focus groups and interviews;
- Formal and informal individual interviews with a sample of student nurses from first, second and third year groups in each case study site. In total, 24 students were interviewed;
- Focus group and formal and informal individual interviews with a sample of key clinical stakeholders including practice development facilitators, placement coordinators, ward managers, mentors, senior nurses and link lecturers in each case study site; in total, 55 participants were interviewed;
- An online ward learning environment questionnaire survey was distributed to a randomised sample of the total population of each student nurse cohort in each case study site; 4,793 with a response rate of 20% (n=937), within the normal range for an online survey;
- Observation of participants in clinical areas over three weeks totalling 60 hours was undertaken where informal interviews with clinical staff and students took place.
We found there have been profound changes for both student nurses and staff who teach, mentor and work with them both in practice and in the higher education setting. These changes include both nurses’ education, such as the move into the higher education sector, and workforce changes in nursing, such as the changes to students’ and HCAs’ roles, brought about partly by supernumerary status.
One effect for students has been an uncoupling of their learning in clinical practice from theoretical learning. For students, one of the signs of this has been that their supernumerary status has become a hurdle which the more successful can negotiate to learn effectively in practice. Students who do not learn to negotiate this may find learning difficult and that their status as students becomes a barrier to learning in a ward team.
We present some data to suggest that student nurses’ supernumerary status affects the way they conceptualise nursing. They question the work they are asked to observe and do because it is performed by HCAs and not by registered nurses.
What is nursing?
The work students were asked to perform was a source of dispute between students and qualified staff and this led to discontent among both groups. Staff felt that students should be learning to deliver what they had themselves learnt to deliver as students, that is, bedside care; however, RNs were often unable to deliver this care because of the busy nature of the clinical areas and therefore students did not see them perform bedside care.
Some staff were aware of the difference between what they encouraged students to learn and what they themselves practised. As O’Connor (2007) found, HCAs’ role was key to understanding what students saw as the nature of nursing. If they observed HCAs delivering hands-on care and qualified nurses involved only in the more technical aspects of care and organisation of the ward, then they understandably aspired to the more technical and organisational roles.
This difference between what qualified nurses actually do (drugs and coordinating ward work) (Mooney, 2007), and what they expected students to do (deliver bedside care) was recognised by participants across the sites. This is illustrated in the following exchange from a focus group between practice development nurses and practice facilitators:
Participant 1: “We’ve changed from being the doers of care to the prescribers of care, so in that sense I think we need to be more advanced in what we think and what we do. I just sometimes feel in despair that by the time students become qualified they still haven’t gained some of the practicalities and common sense, and stuff that we would have learnt as a student, things like time management, basic assessment skills, that we would have automatically been doing on our first ward. Okay, we may have only done the washing, but we had to get them all done at a certain time; therefore we had time to manage.”
Participant 2: “Because some students don’t perceive doing nursing care as nursing, but the healthcare assistants do so much work that we as students used to do, they don’t see themselves as learning any more.”
Participant 1: “I think that’s a big difference. If they’d just done basic nursing care, it’s not basic, but washing whatever, they [say they] haven’t learnt anything all morning. And I think ‘Well, actually you have. You’ve worked very hard all morning and you’ve given what you’re supposed to be giving – nursing care’.”
Participant 3: “I think you’re quite right there because I have staff coming to work, permanent staff coming to work, they’re so keen to get to know how to do all the advanced practice care, that the basic stuff that you have to have a good grounding in before you can advance on to the more difficult tasks, the more acute tasks, they just don’t want to do.”
Participant 2: “They don’t perceive it as nursing.”
Student nurses were well aware that qualified nurses did not deliver bedside care and resisted attempts from staff to direct their work which interfered, as they saw it, with their learning. We recorded the following in our fieldnotes from a morning A&E shift:
“I had come on at 07.30 and watched handover and then walked out with the ‘minors’ team including two students. The night staff nurse handed over a lady from a care home who’d fallen over, was mildly concussed and needed rehydrating. She said: ‘That elderly lady needs this tea,’ and pushed the beaker towards the two students; neither of them moved. I then went and gave the tea. Later that morning, the student and I went up to watch a scan and I was explaining the physiology behind this to her; she observed that this was helpful and she’d learnt something. She then said had I observed her not giving the elderly lady that beaker of tea? Of course I said ‘Yes’ and she then went on to say: ‘I keep being asked to do things which won’t help me learn – clear up poo, mop up blood; give patients tea and toast. I realised that I needed to be more focused to learn and I don’t do those sorts of things now. I hadn’t learned anything today – I’ve observed triage which had lasted five minutes, transferred someone to discharge (10 minutes) – I’ve refused to do an ECG as I spend all my time doing that.’”
Of course, this student nurse was working within the parameters of supernumerary status – she did not see helping a patient with a cup of tea as a learning opportunity. However, none of the trained nurses pointed out what could have been learnt from this task; neither did they challenge her behaviour. But these student nurse choices have consequences. If they do not do bedside work, they risk alienating qualified staff, and they may be perceived as lacking common sense and practical experience.
Nurse lecturers and tutors believe bedside nursing is a learning opportunity for students, and part of registered nursing practice, as this extract from our interviews confirms:
Researcher: “Do they ever come to you and say: ‘This ward hasn’t been good for my learning?’”
Nurse tutor: “Oh yes, a lot of them feel very frustrated, saying they can’t learn what is needing to be learnt on that ward because the ward is just not a good learning environment. I think some of that stems from the modular framework that we have in their programme where set learning outcomes have been identified and they don’t feel that the practice opportunities match. It does take quite a bit of convincing to show a student that actually if they look at the learning outcomes more broadly they can be achieved in almost any practice learning environment.”
Senior tutor: “I think things need to be clear about what it is they get out of a placement. We have students doing a portfolio, and it’s trying to tease out and help the student to identify how they can meet this learning outcome.”
Senior lecturer: “That does really stand out when someone goes to a care home and all they can see, in inverted commas, is ‘basic nursing care’. They’re stuck, they don’t know what nursing is, and some of them really resent having to do that type of work. But I think there’s always been a sense of that. I couldn’t tell you whether that’s worse or better but students don’t expect to deliver practical nursing care for very long at all.”
One tutor and two lecturers felt that students did not consider bedside care to be part of nursing because there was a lack of leadership and supervision.
Nurse lecturer: “I have seen very little supervision of students, I have seen students walking around aimlessly, I’ve seen students doing bad practice, I have seen students actually doing illegal or dangerous acts But, those are the issues, things not being filled in, things not being done, very basic things like people not washing hands or using handgel is not picked up. But that’s leadership - people owning the clinical experience in their environment or not.”
Senior tutor: “I think with the student nurses, the junior sisters do not have sufficient experience to pass onto the students. They’re not comfortable enough in their role to be able to support students efficiently.”
Researcher: “And is that what you’ve observed?”
Senior tutor: “Yes, that’s what I’ve observed. And they don’t necessarily know how to tackle student problems or things that students do that are not right in the ward.”
Researcher: “And have you got an observation of that in mind?”
Senior tutor: “The patient had a urine drainage bag and the student put it on the top rail of the cot’s side and the staff nurse saw this happen, she didn’t say anything to the student, she didn’t observe it. It wasn’t until I said to her that you ought to tell the student to put it a bit lower for drainage purposes, but she didn’t even recognise that there was a problem. And it is their experience, I think, that is a poor role model for the students.”
Senior lecturer: “The other thing is that the staff nurses in that [unit] like the idea of giving out medication…rather than trying to think about a very difficult area…about how you get somebody out of bed when they’re really angry. It’s unusual to have someone focus on that at any level other than care assistants. At the end of the day if it’s the healthcare assistants caring… [students] … may think that’s not what we [nurses] do.”
There were many incidents in the data which led us to ask why students rejected what to qualified nurse participants was the crux of nursing: bedside care. Perhaps this is not surprising given the skills that students observe qualified nurses performing.
The data suggests that qualified nurses focus on tasks which only they can do, while students continue to deliver unqualified care, now supervised by HCAs. This concentration and division of labour between qualified and unqualified workers has led to a division by students of nursing work into high and low status work (as described above), a position similar to that identified by Ousey (2006).
Scott (2008) argued forcibly that the workforce orientation of the NHS in both nursing practice and education has produced a concentration on skills and competencies rather than on caring, which focuses on the patient and is built on a good relationship (relational caring). She suggested that this new form of instrumental caring puts obstacles in the way of achieving patient-focused care and egalitarian nurse-client relationships.
What is nursing?
These findings have led us to ask a fundamental question: what is nursing? This is a question that has bedevilled nursing as an occupation since its inception (Baly, 1995), and on which there is little agreement.
For example, Goddard (1953) argued that nursing could be defined as technical, affective and basic work and subsequent studies (for example, Alexander, 1983) found that nurses and student nurses valued these components of nursing work differently; each was assigned low or high status. This is borne out by more recent work by Allan (2007) and Smith et al (2006) into the delivery of caring work by overseas-trained nurses.
Our data suggests that students value technical work more highly than caring work because they see qualified nurses undertaking technical work. While these nurses may value caring work, their values are not being transmitted to students who feel devalued because of the work they do on the wards. This is partly because students do not feel they are treated as members of ward teams. As one of our interviewees said:
“Doctors see their students as junior colleagues whereas nurses see students as labour.”
If bedside care continues to have a low status, then doing it may lead to students feeling stigmatised and could leave them feeling unprepared for their future role as qualified nurses who do not have time to perform such tasks.
The relationship between the low status of bedside care, the role of qualified nurses and stigma is complex and may be interpreted in a variety of ways. Students may be made to feel outsiders to the ward nursing team and in particular the professional nurses they aspire to be. They may feel that because the ward team does not have the time to supervise them, they are given low status “care” which is believed not to need supervision. The effect on students is to make them feel devalued, marginalised and “stupid”.
Both Gordon Brown and David Cameron argue that professional nursing skills and bedside care are not mutually exclusive. We hope that the Commission on the Future of Nursing and Midwifery considers some of the issues we raise in this article which concern how student nurses learn in their supernumerary role, which in turn affects how they think about nursing.
There is clearly a mismatch between trained and student nurses’ views of what nursing is and what student nurses need to learn.
We would like to thank our co-researchers Maria Lorentzon and Mike O’Driscoll and the study participants.
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