whistleblowing and student nurses – are we asking too much?
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Nurse Education in Practice 12 (2012) 177–178
Contents lists available
Nurse Education in Practice
journal homepage: www.elsevier .com/nepr
Editorial
Whistleblowing and student nurses – Are we asking too much?
Introduction
As a group of nurse educators we have, on occasions, been facedwith situations where pre-registration students have raisedconcerns about patient care.While, as an institution, we have robustformal systems inplace for students to escalate concerns about prac-tice, the outcome of high profile inquiries locally (Vale of LevenHospital), and nationally (Mid Staffordshire NHS Foundation Trust)alongside recent publications (Care Quality Commission, 2011)prompted us to deliberate someof the issues aroundwhistleblowing(more recently referred to as ‘escalating concerns), by studentnurses. This editorialpresents aflavourof our reflectionsasweposedourselves the question – ‘Are we are asking too much of students?’
Fitting in
Student nurses attend clinical placements anticipating that theywill learn to become a member of the group of registered nursesthey see around them, who act as their role models and mentors.In the first instance however students need to understand what isrequired of them as student nurses. Brennan and McSherry (2007)discuss the socialisation of Health Care Assistants (HCA) into thestudent nurse role. They indicate that there is a tendency for suchstudents to fall back into the ‘comfort zone’ of their previous HCArole to enable them to be accepted in a new placement. Studentswithout this background need to develop an identity as a studentnurse, guided by the expectations of their mentors and other quali-fied staff without any ‘comfort zone’ in the placement setting. It isnot surprising therefore that there is a need to ‘fit in’with thepatternof behaviour of the qualified staff they see as their role models. Butare student nurses actually observing staff escalating concerns inpractice?
Expectations
Healthcare workers worldwide are expected to raise concernsabout failures in standards of care where patients are beingexposed to situations that could cause unintended harm (WHO,2005). The prevalence of adverse events in healthcare have beendocumented since the 1990’s and attempts have been made tomanage these through incident reporting and the development ofopen responsive healthcare organisations with no blame cultures(Kohn et al., 2000; National Patient Safety Agency, 2005). Thefundamental element of these systems is that staff, within the orga-nisation, are willing to report situations where they feel patientsare being put at risk of harm. The reporting of failures of standardof care has not been without its challenges for nurses. Gallagher
1471-5953/$ – see front matter � 2012 Elsevier Ltd. All rights reserved.doi:10.1016/j.nepr.2012.04.002
(2010) argues that the fear of being seen as disloyal to the organi-sation or to colleagues, personal reprisals and, in circumstancesof reporting outside the organisation of breaching patient confiden-tiality may lead to underreporting. In an attempt to protect health-care workers from reprisal, legislation has been passed in somecountries, however recent surveys have shown that nurses remainapprehensive about raising concerns (RCN, 2009, 2011).
Students’ dilemmas
Where the behaviour of qualified staff challenges the students’expectations of a good nurse, students are faced with a difficultdilemma. Bellafontaine (2009) explored this dilemmaand identifiedthe student–mentor relationship as one of the key factors influ-encing a student’s ability to report potentially unsafe practice. Sheindicates the importanceof rolemodelling and the fact that studentshad not seen qualified nurses’ report poor practice. In the absence ofrole models who encourage the reporting of poor practice, is itreasonable to expect that students can take on this role?
Students in the Bellefontaine study were also afraid of theimpact on assessment and, similar to healthcare workers generally,the possible ‘aftermath of reporting’. In our experience, this fear ofan impact on assessment is expressed by students when the possi-bility of reporting poor practice is discussed. Progression concernsare seen by students as a valid reason to avoid becoming involved inwhat could potentially be a stressful and challenging process.
It could also be argued that students who are on a three or fouryear journey towards registration lack the knowledge and experi-ence to distinguish departures from university taught evidencedbased care which they often encounter in practice. In our experi-ence students may raise concerns about practice they have wit-nessed; however, on further discussion we discover that theyhave not understood the professional decision making which hasunderpinned the deviations from evidence based care sometimesrequired to give patients’ individualised care.
Such obstacles, as outlined above, may prevent student nursesreporting concerns therefore should we accept that we are perhapsasking too much of our students or should we try to navigate theseobstacles?
Students’ role in escalating concerns
Students often discuss their concerns with their peers in reflec-tion classes and so we already know that they are recognising, andworrying about, poor practice. Patient safety is also a core elementof nursing programmes and so it is impossible to ignore thestudent’s role in expressing their concerns if they see practice
Editorial / Nurse Education in Practice 12 (2012) 177–178178
which is harmful. Student nurses are expected to report failures instandards of care along with other healthcare workers, and regula-tory guidance clearly states that they should inform their mentor orlecturer if they believe that they, a colleague or anyone else may beputting someone at risk of harm, have suffered harm or areunhappy about their care or treatment (NMC, 2010).
Knowledge deficits, especially in the early stages of their pro-gramme, may impact on the student’s ability to challenge practice;however, as consumers can they not tell if care is good or bad?Many students are users or carers themselves and as such theiropinion should be highly valued even at an early stage.
Students enter practice areas and look at the environment witha ‘fresh’ pair of eyes and as such may notice deficits in care whichhave become embedded in a practice area and gowithout challengeas ‘things have always beendone thatway’. Moreover, students haveoften not yet established close relationships with staff and may nothave toworry about continuing towork in the specific environment,therefore are they not in some ways advantaged in their position?
Resolving the dilemma
We do ask a lot of students and it is dangerous to accept that weshould be reliant upon student nurses in finding fault with practice,especially when qualified staff, without some of the aforemen-tioned obstacles, are often deterred from speaking out. Howeverin the current climate of ‘failings in care’ discussing the implica-tions of whistleblowing for the student nurse is paramount. Aseducators with a professional qualification we have to encouragestudents to raise concerns, provided they have clear guidance aboutthe correct procedure and adequate support from us as educators.Education providers should teach students, at an early stage, tosee these events as learning opportunities and use reflection asa way of investigating the evidence to establish if this really ispoor practice prior to raising concerns. Our willingness to listen,support, take necessary action and feedback the outcome ofstudents’ practice concerns are key to managing this dilemma.
Teaching, using bad practice as an example, is often not an appro-priatemethod of education. Thismay bewhy, as nurse educators, wehave some discomfort in the subject of escalating concerns. Prefer-ence is to highlight good practice and encourage students toremember that these incidents are not the norm. However, perhapsthis can still be done by supporting students in changing practicefor the better?
References
Bellafontaine, N., 2009. Exploring whether student nurses report poor practice theyhave witnessed on placements. Nursing Times 105 (35), 28–31.
Brennan, G., McSherry, R., 2007. Exploring the transition and professional socialisa-tion from health care assistant to student nurse. Nurse Education in Practice 7(4), 206–214.
Care Quality Commission, 2011. Raising a Concern with CQC – A Quick Guide toHealth and Care Staff About. Available at. http://www.cqc.org.uk/sites/default/files/media/documents/20120117_whistleblowing_quick_guide_final.pdf(accessed 06.01.12.).
Gallagher, A., 2010. Whistleblowing: what influences nurses’ decisions on whetherto report poor practice? Nursing Times 106 (4), 22–25.
Kohn, L.T., Corrigan, J.M., Donaldson, M.D., 2000. To Err is Human: Building a SaferHealth System. A report of the Committee on Quality of Health Care in America.Institute of Medicine. National Academies Press, Washington, DC.
National Patient Safety Agency, 2005. Building a Memory, Preventing Harm,Reducing Risks and Improving Patient Safety – The First Report of the NationalReporting and Learning System and the Patient Safety Observatory. NationalPatient Safety Agency.
Nursing and Midwifery Council, 2010. Raising and Escalating Concerns Guidance forNurses and Midwives. Nursing and Midwifery Council, London.
Royal College of Nursing, 2011. Nurses Still Afraid to Blow the Whistle. Available at.http://www.rcn.org.uk/newsevents/press_releases/uk/nurses_still_afraid_to_blow_the_whistle_-_rcn (accessed 30.01.12.).
Royal College of Nursing, 2009. RCN launches phone line to support whistleblowingnurses. Available at. http://www.rcn.org.uk/newsevents/news/article/uk/rcn_launches_phone_line_to_support_whistleblowing_nurses (accessed 30.01.12.).
World Health Organisation, 2005. WHO Draft Guidelines for Adverse Event Report-ing and Learning Systems. World Health Organisation, Geneva.
Kathleen Duffya,),1, Jacqueline McCallumb,2, Valerie Nessc,3,Lesley Priced,4
aNHS Lanarkshire, Practice Development Centre,14 Beckford Street, Hamilton ML3 0TA, UK
bCaledonian University, Room A511, Govan Mbeki Building,Cowcaddens Road, Glasgow G4 0BA, UK
cCaledonian University, Room A417, Govan Mbeki Building,Cowcaddens Road, Glasgow G4 0BA, UK
dCaledonian University, Room A534, Govan Mbeki Building,Cowcaddens Road, Glasgow G4 0BA, UK
* Corresponding author. Tel.: þ44 (0)1698 201424;fax: þ44 (0)1698201423.
E-mail addresses: [email protected] (K. Duffy);[email protected] (J. McCallum); [email protected]
(V. Ness); [email protected] (L. Price)
1 Present address: 22 Allendale, Stewartfield, East Kilbride G74 4JD, UK.2 Present address: 9 Birklands Wynd, Kilwinning, Ayrshire KA13 6NP, UK. Tel.: þ44(0)141 331 3068; fax: þ44 (0)141 331 8312.3 Present address: Flat 2/1, 140 Raeberry Street, Glasgow G20 6EA, UK. Tel.: þ44 (0)141 331 8813; fax: þ44 (0)141 331 8312.4 Present address: 122 Comiston Drive, Edinburgh EH10 5QU, UK. Tel.: þ44 (0)141331 3431; fax: þ44 (0)141 331 8312.