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OPINION

June Girvin: 'Education must prepare nurses to speak out about poor care'

  • 11 Comments

The importance of humanities to nurse education should not be underestimated, says June Girvin

The Francis report findings and the more recent revelations from Morecambe Bay have led to much discussion about how best to respond to the growing realisation that all is not well in some healthcare organisations.

Responses include “pre” pre-registration experience for student nurses, improved leadership training and increased monitoring. Organisations have critical incident and “near-miss” reviews, and whistleblowing policies are widespread.

My faculty has a long-standing whistleblowing policy for students and provides support to those who choose to use it. But policy can only do so much when the root of the problem lies in organisational culture.

“How well do we prepare students to understand the nature and importance of exercising their professional conscience and the ethical, legal and human rights structures that protect and encourage speaking out?”

The history of openness around clinical care is neither a long, nor glorious one. The most cursory look at the literature on speaking out against poor practice reveals victimisation, career limits, ostracism, defensiveness, obfuscation and blame shifting. The weakness of the individual against the organisation and the power of professions and senior management combine to make whistleblowing a risky choice to make. A choice that is particularly hard for more junior staff, even though they may retain more of the idealism of the ethical behaviour of their organisations.

Socialisation into organisational norms blunts those expectations over time. Perhaps there is more that education can do to strengthen the resilience of health professionals when faced with a potential whistleblowing situation. How well do we prepare students to understand the nature and importance of exercising their professional conscience and the ethical, legal and human rights structures that protect and encourage speaking out?

When pre-registration nursing moved into higher education in the early 1990s it was with expectations that there would be benefits from exposure to the broader humanities subjects, such as law, ethics and the social sciences.

Many universities worked hard to draw these elements into the curriculum to develop nurses who had sufficient knowledge to practise competently with compassion and courage, and to be committed to high standards. Over the years however, the pressures on the curriculum have been relentless. Changing expectations of newly qualified nurses and a curriculum driven by commissioned utilitarianism have led to a concentration on mechanistic skill development and a devaluing of knowledge not associated with clinical practice and biomedical systems.

The original concept of the graduate nurse as “knowledgeable do-er” with the capacity for reflection and handling uncertainty is channelled more and more towards becoming a competency-proficient, system- compliant, process-driven operative.

The same is true of learning beyond registration. The demand is for clinical skill-based programmes, which is not unreasonable, but it is at the expense of opportunities to explore the dilemmas of 21st century practice and how to influence and contribute to it. Is it this change that has led not just to a reluctance, but an inability of staff to exercise their moral conscience and denounce inadequate care?

Education has an obligation to prepare professionals not only to be competent practitioners, but also to be confident judges of other people’s practice and to see the identification of poor practice as a vital part of their role.

Humanities needs to be embraced back into education. By setting professional preparation and ongoing education in a broader context, students will be better prepared for the dilemmas and tensions by which their practice is surrounded.

● The views expressed in this article should not be interpreted as my employer’s views

June Girvin is pro-vice chancellor and dean, Faculty of Health and Life Sciences at Oxford Brookes University

 

 

  • 11 Comments

Readers' comments (11)

  • michael stone

    'The most cursory look at the literature on speaking out against poor practice reveals victimisation, career limits, ostracism, defensiveness, obfuscation and blame shifting. The weakness of the individual against the organisation and the power of professions and senior management combine to make whistleblowing a risky choice to make.'

    YES - SPOT ON!

    How the heck does 'educatiing clinicians that they should speak up' (something they should already grasp anyway!) address those issues ? Sort out those issues of 'bullying etc' - don't keep going on about 'it is your duty to speak up' and please make it SAFER to raise concerns !

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  • Good article June. I've been banging on for some time about better equipping nurses to challenge and be challenged. Bullies don't flourish in environments where there is confidence to question and be questioned. All the policies in the world will not make an ounce of difference unless they are applied by competent, fair minded people. To create safer working environments, you have to start with the people who work in them. That is true for students and qualified nurses alike.

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  • michael stone

    mags | 10-Jul-2013 11:33 pm

    Mags, I almost always agree with you about things, and I agree that 'the enviroment' can be altered to disfavour bullies (or, rather, to dissuade them from actually trying to bully people).

    But there seem to be plenty of cases of people who were 'equipped to speak out' and who spoke out, and then were suspended, hounded out, faced 'trumped-up' accusations of incompetence, etc. So unless your point is simply that if most people were to speak up, it would be harder to bully them, I'm wondering if we are different on this one ?

    I want an anonymous 'raising of concerns' system, for concerns which are about 'bad systems, lack of resources, etc' (not 'Fred isn't competent' - you can't have anonymity for ad hominem complaints) so that the system itself, makes it impossible to 'bully' whoever raises the concern, by leaving the identity of that original person unknown.

    So you seem to want to change 'the staff' whereas I (initially - I do also want the change you describe as well) want to protect the staff, by changing 'the system' ?

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  • Mike. It isn't an either/or here.

    Structures and systems must be in place and must be robust enough to support and protect anyone raising concerns. Much is already written about that on these threads.

    However, when you say that there are "people who were equipped to speak out", you have missed out that they are often alone in doing so. Yet nurses rarely work in isolation. Which begs the question; where are the colleagues who are sharing the same problems and challenges? It isn't just about some well equipped people speaking out. It is about enough well equipped people speaking out. I would further argue that a confident, articulate workforce would stop situations getting to the point where they had to access anonymous whistle-blowing procedures.

    Believe it or not, most of the existing policies and procedures would be effective if they were interpreted and applied as they were intended. Systems are only as effective as the people who work within them. It has to start with people.







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  • michael stone

    mags | 12-Jul-2013 11:44 pm

    Mags, I agree with you, and especially with your final paragraph - but I wasn't thinking merely about nurses who have been 'set upon' for raising concerns, because there are plenty of cases of senior doctors and people quite high-up the management chain who have been 'bullied out' for pushing issues.

    So, it is the solution to this bit:

    'most of the existing policies and procedures would be effective if they were interpreted and applied as they were intended'

    where we are haggling: I want systems and policies to be designed to thwart 'inappropriate interpretation', and that is where I would argue the solution has to start from.

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  • michael stone | 13-Jul-2013 9:44 am

    Mike, whereas we both agree on solutions, I think you and I will always disagree on the starting point here.

    The nursing profession has a collective inferiority complex which seems to cause a crippling paralysis when it comes to sticking up for itself. It is not based on a fear of consequences. It is based on the belief that we don't have anything important to say and that we should really just do as we are told by doctors, managers, the public, the government. There are no nurses in leadership positions in government. The English CNO was down-graded from being responsible directly to government ministers to being answerable to a department. Repeatedly, we are singled out for the brunt of blame for ANY shortcoming within the NHS or any other healthcare setting. Instead of challenging any of this, we meekly ACCEPT the blame and promise to do better by vomiting forth the worst kind of bilge (6Cs, care champions, etc). None of this has to do with systems.

    Nurses are not taught to challenge. That really really needs to change.

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  • michael stone

    mags | 13-Jul-2013 11:55 am

    'Nurses are not taught to challenge. That really really needs to change.'

    As an outsider, that has been my conclusion as well. But, almost all clinicians are 'very polite' in comparative terms - presumably, partly because you interact with patients.

    When I ask clinicians questions, I want them to explain to me where I'm either right or wrong, but often I can't get that: scientists will START with "You've got to be wrong about this, Jim, because ..." but most HCPs 'are much more polite'.

    Doctors do seem to be 'more forceful' than nurses, but this gets us back to those questions about hierarchical and gender issues, which provoke mixed responses from nurses.

    So I agree that nursing has got a particular problem with 'timidity' or whatever, but there is still a serious problem with 'bullying' even of senior doctors and senior managers, in parts of the NHS. And I suspect that Nicholson (hope I've remembered the right name !) would claim that even he 'is being bullied out of his job' !

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  • tinkerbell

    michael stone | 13-Jul-2013 2:55 pm
    And I suspect that Nicholson (hope I've remembered the right name !) would claim that even he 'is being bullied out of his job' !


    Sorry Mike, But ...................What a load of arse. He was a henchman sent in to do a hachet job which he has achieved and is now getting his payoff.

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  • tinkerbell

    that's 'hatchet' job.

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  • michael stone | 13-Jul-2013 2:55 pm

    'Doctors do seem to be 'more forceful' than nurses, but this gets us back to those questions about hierarchical and gender issues, which provoke mixed responses from nurses'
    .......and that brings us back to being able to challenge the status quo! mags is right. people and how they behave are key. you seriously underestimate how much bullies love timidity in others.
    your comment about HCPs being more polite in their dealings with you doesn't prove much. some of the most 'polite' people i know are the most manipulative and the biggest bullies. I also agree with tinkerbell re:nicholson. you are way of there i'm afraid.

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