A student nurse used her personal experience as a patient to improve her own and other students’ nursing care to make it centred around the patient as a person.
Service-user involvement is a growing aspiration for health professionals and those involved in nursing education. This article describes one approach to integrating theory and practice through service-user involvement in a teaching setting. Gwen Carter, a student nurse, tells her story of becoming a patient and how reflecting on this experience affected her approach to patient care. By sharing her experience with peers and mentors, she was able to influence their approach to care, and made a difference to how mentors worked with students in practice.
Citation: Carter G et al (2012) Effects of being a patient on student development. Nursing Times [online]; 108: 20, 21-23.
Authors: Gwen Carter was student nurse, School of Nursing and Midwifery, Robert Gordon University, Aberdeen, at the time of writing; Ruth Taylor is associate head of school, School of Nursing and Midwifery, Robert Gordon University, Aberdeen.
- This article has been double-blind peer reviewed
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Standards for pre-registration nursing education emphasise the importance of ensuring that the public can be confident that all newly qualified nurses “practise in a compassionate, respectful way”, and that they “work in partnership with… service users, carers and their families ensuring that decisions about care are shared” (Nursing and Midwifery Council, 2010).
The Prime Minister’s Commission on the Future of Nursing and Midwifery (2010) set out a vision for high-quality, compassionate care in a context in which service user, carer and family involvement are central to the care experience. In Scotland, the healthcare quality strategy argued that the public wants an NHS that is caring and compassionate and prioritises clear communication and collaboration with patients and others (Scottish Government, 2010). These policy drivers indicate that service users should be at the heart of the healthcare experience. Nurses are well placed to take forward compassionate, person-centred care in this rapidly evolving healthcare context.
This article describes one person’s approach to enabling student nurses (and others) to glimpse and internalise aspects of the experience of being a patient.
Key to the story is the fact that this person, Gwen Carter, is a student nurse who became a patient. She tells us about her journey, emphasising aspects of her experience that helped her to understand the nurse’s role better than she had before, and which inspired her to share her insights with her peers.
Background and context
The engagement of service users (patients, clients, carers, families) in nursing education is crucial to developing nurses who are well prepared for the challenges of practice and who can work collaboratively with service users (Lathlean et al, 2006).
There are many approaches to implementing meaningful involvement of service users, for example in:
- Student nurse selection (Rhodes and Nyawata, 2011);
- Assessing practice (Stickley et al, 2011);
- Reference groups (Lathlean et al, 2006).
One way to ensure that such engagement is integrated into theoretical learning is to create opportunities for service users to come into universities to speak to students about their experiences. The use of narrative or storytelling has provided insights into the healthcare experiences that professionals provide (Haigh and Hardy, 2011).
Offering students opportunities to “connect theory with practice” (Binding et al, 2010) is extremely useful in helping them to bring together their understanding of theoretical concepts (such as empathy) alongside the realities of working in practice.
Binding et al (2010) asked: “How often is suffering caused by the inability of reaching others with words, a look, or the touch of a hand?” Skilled reflective practice enables (student) nurses to look at themselves and be aware of other people (service users) so a connection can be made between what is known theoretically and what is enacted within a relationship.
What Ms Carter describes below is a “looking back” on experiences (Stockhausen, 2006), alongside a continuing “looking into” practice through the eyes of someone who can, exceptionally, shed light on the impact of nursing practice on the overall patient experience.
What she reveals is an approach to reflection that she has been able to take hold of, share and continue to use in interactions with her peers, mentors and patients, thus influencing practice through others’ therapeutic/personal growth.
Ms Carter’s story
As a student nurse, my role changed to that of patient following a diagnosis of advanced breast cancer.
I underwent several surgeries, chemotherapy and radiotherapy, and had to face physical, psychological and emotional problems I was ill-prepared to manage effectively.
I was overwhelmed by feelings of vulnerability, isolation and anxiety, which were exacerbated by symptoms of my decreased health and strength, and side-effects of treatments. Even as a “know-ledgeable” patient, I found it difficult to retain any sense of control over events relating to my health or the wider scope of my personal life.
To cope with the complexity of my condition, I tried to understand the experience concurrently on two levels: first, to meet my personal needs as a patient; then more objectively and logically from a nursing perspective, ultimately as a tool to consolidate my knowledge and practice. This reinforced the hope that I would be able to return to nursing, gave me a goal to focus on and generated positive thoughts about my future.
I had gained an almost unique insight into the patient journey, with a simultaneous view from the positions of both patient and nurse. By reflecting on my experience, I identified elements of nursing care that had either aided my recovery or made me feel more anxious and vulnerable. I thought about why these events occurred, their effects and whether alternative approaches could have improved my patient journey.
As a result, my patient experience had more impact on my nurse education than any other learning opportunities I encountered, causing me to re-examine my practice and explore ways of sharing my experience to contribute to the development of other students and nursing staff.
The desired outcome would be to improve the experience of other patients by encouraging healthcare staff to wholly embrace the principles of person-centred care and be more responsive to the intrinsic needs of individual patients.
I prepared and presented a talk to student nurses to share a comprehensive patient view of breast cancer diagnosis and treatment. Alongside specific breast cancer information, I included important aspects of general nursing care that would apply to every patient and condition, such as communication, empathy and person-centred care.
The importance of developing a therapeutic relationship with patients and respecting their individuality and personhood were illustrated using examples of good and poor practice (Boxes 1 and 2).
Box 1. Good practice
Three days post mastectomy, I was feeling particularly low, and a student nurse came to listen to my concerns, and decided to take me off the ward to wash my hair.
As we went to the bathroom, she was stopped by a staff nurse and reminded to complete previously allocated tasks. She replied with confidence that her priority at that moment was washing my hair, and she had delegated other duties.
Analysis and learning
This student nurse recognised my anxiety, encouraged me to share my feelings and discuss why I felt that way.
She showed interest and compassion, and talked to me as a person and not just a cancer patient. She had the confidence to make time for me as an individual, challenging task-oriented colleagues and adapting to developing situations. Washing my hair restored a feeling of normality as we talked about light-hearted topics unrelated to health.
This incident perfectly encapsulated the principles of person-centred care, recognising and reacting to the changing needs of individual patients, and placing communication and empathy at the heart of nursing practice.
Box 2. Poor practice
I told the students about an incident where a specialist nurse told me that my breast lump did not feel sinister and was nothing to worry about.
Only an hour earlier, I had been told I had multi-centric high-grade malignant tumours, so the comment about there being “nothing to worry about” resulted in a loss of trust and made me reluctant to ask for information and support when I needed it.
Analysis and learning
Many students in class were honest enough to admit they had been in a position of serving platitudes to patients; we talked about these incidents to explore why they had happened and discuss alternative approaches.
In all cases the students had been trying to avoid dealing with patient distress, a common reaction discussed by Towers (2007) and Kelsey (2005) and one that students had adopted after observing it in trained colleagues’ practice.
Impact on practice
Students were asked to complete a short paper-based evaluation of the session, in which they provided feedback on what they had liked, what could have been improved and what they felt they had gained from it.
The evaluation revealed a number of positive outcomes illustrated in the quotes below. Almost all students recognised that they needed to develop some aspect of their communication skills and identified ways to achieve this.
Students said the talk had added another dimension to their learning experience as it stepped away from theory and policies, and encouraged them to see a patient rather than simply a condition or task:
“[The talk] shows you how it affects the person, for example hair loss. These are things that books don’t provide.”
Many students felt they were prevented from delivering holistic person-centred care because of the task-oriented attitudes of trained staff:
“I feel it is the nurses who influence the student nurses. Students want to apply theory to practice and learn to think for themselves, but staff nurses prevent this.”
They also felt this talk had made them realise that they could make a difference as students, and they would now have the confidence to negotiate with mentors so listening to patient experience would be included in their learning objectives:
“I will be more aware of what I say to people and how I say it. I liked your story about the student nurse. It has inspired me to care in the same way.”
The ripple effect
I have shared the feedback from my session with staff nurses who mentored me in subsequent placements.
They commented that students focus strongly on the practical skills in the NMC essential skills cluster (NMC, 2010), and most have little confidence in less well-defined skills such as communication, empathy and person-centred care.
The mentors I spoke to were inspired by the feedback from this talk to review their practice to incorporate the student views. One of their suggestions to achieve this was to ask students to write up a case study on placement, driven by patient comments on their experience.
Mentors said that trained staff do not always make adequate time to talk or listen to patients, giving understaffing and paperwork as the reasons, but that all staff, not just students, needed to reflect on this aspect of their practice.
Students and mentors said they felt it would take more than one individual’s change of practice to improve care measurably. However, this experience demonstrates that the opportunity to use one person’s experience as an example of how care approaches affect patient experience can provoke a “ripple effect”.
In this case, the ripple effect came from discussions with my mentors, who then changed their approach to supporting student learning, and discussed the issues more widely with colleagues. This project has shown that small steps in the right direction can gather pace and it has instilled that confidence in at least one large student group.
As students and nurses, we recognise the value of reflection and continually use it to make sense of events, feelings and actions experienced in daily practice (Binding et al, 2010). The benefits of reflection are most appreciated as we re-encounter events and are better equipped to improve or challenge our practice with confidence.
In regaining control of my future, I worked through the issues of my illness, adapted my goals and resumed my career with a more focused idea of the standard of care I want to deliver. Without knowledge of the structure and process of reflection, I would not have been able to move forward so positively and confidently or to use many aspects of my personal and professional reflections to develop my nursing practice.
As both a nurse and a patient, I have found immense benefit in reflection and wondered whether other patients would find the same process useful to resolve their issues and problems.
While not every stage of the process nor the formal structure would apply to every patient, I find the template for the reflective process useful when consulting patients about specific problems. I can direct the conversation along reflective stages, encouraging patients’ own problem-solving skills and find they are more empowered and motivated to take control of events, which increases compliance and leads to a more individualised care plan.
Ms Carter’s story appears to have changed the ways in which some of the students and mentors who encountered her experience (albeit secondhand) see their role within their therapeutic relationships with service users.
Her reflective approach has enabled her to draw real insights into how relationships with patients can be enhanced. In particular, her unassuming narrative appeared to affect significantly student nurses in one classroom session so that many felt able to articulate that they wished to change aspects of their practice.
Although the “evidence” provided here for the impact of Ms Carter’s story is anecdotal, this project indicates that students value the linking of theoretical concepts with a real patient situation.
The ripple effect of her story (through mentors) demonstrates that there is much value in nurses really taking time to hear what it feels like to be a service user. Backed by a strong theoretical backbone and skilled reflective practice, learning through patients’ stories and narratives appears to be one way to help students to integrate theory and practice to improve patients’ healthcare experience.
It may be useful to think more about how these stories can affect learning in practice, particularly as Ms Carter found mentors hugely receptive to what she had to say as they then found ways of working with their students differently.
Ms Carter has agreed to continue to work with the School of Nursing and Midwifery as she has now completed her course and moves into a newly qualified role.
- Policy is aiming to put service users at the heart of the healthcare experience
- Nurses are ideally placed to take compassionate, person-centred care forward
- Engaging service users in nursing education is crucial to developing nurses who are well prepared for practice
- Storytelling has provided insights into the healthcare experiences that professionals provide
- This patient story appears to have affected how students and mentors see their therapeutic relationships with service users
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Haigh C, Hardy P (2011) Tell me a story - a conceptual exploration of storytelling in healthcare education. Nurse Education Today; 31: 408-411.
Kelsey S (2005) Improving nurse communication skills with cancer patients. Cancer Nursing Practice; 4: 2, 27-31.
Lathlean J et al (2006) Experiences of service user and carer participation in health care education. Nurse Education Today; 6: 424-429.
Nursing and Midwifery Council (2010) Standards for Pre-registration Nursing Education. London: NMC.
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Rhodes C, Nyawata I (2011) Service user and carer involvement in student nurse selection: key stakeholder perspectives. Nurse Education Today; 31: 439-443.
Scottish Government (2010) The Healthcare Quality Strategy for NHSScotland. Edinburgh: Scottish Government.
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Towers R (2007) Providing psychological support for patients with cancer. Nursing Standard; 22: 12, 50-57.