An investigation into whether student nurses report poor practice they have witnessed on clinical placements, and the factors that influence their decisions
Nerys Bellefontaine, MSc, PGDip, PG Cert (Ed), RGN, is professional development nurse for clinical practice, Outer North East London Community Services. At the time of carrying out the research, she was a practice experience facilitator for a London PCT.
Bellefontaine, N. (2009) Exploring whether student nurses report poor practice they have witnessed. Nursing Times; 105: 33, early online publication.
Background: While literature suggests that nurses report incidents or potentially unsafe care delivery, there is little evidence on student nurses’ practice in this area.
Aim: To explore the factors that influence student nurses in reporting concerns about practice.
Method: A qualitative study was carried out using a phenomenological approach, based on semi-structured interviews with six student nurses.
Results and discussion: Student nurses said they do not always report potentially unsafe practice they have witnessed. Four main themes were identified: the student-mentor relationship in clinical placement; actual or potential support provided by both the practice area and university; students’ own personal confidence and professional knowledge base; and fear of failing clinical placements.
Conclusion: The nursing profession needs to take stock of current organisational culture and practice, and address issues around reporting in practice. Recommendations are made to improve mentorship, nurse training and for further research.
Keywords: Student Nurses, Poor practice, Incident reporting, Patient safety
* This article has been double-blind peer-reviewed.
* Preparation for mentors needs to explore students’ need to belong on placements, and mentors need to be positive role models for them.
* There is scope to adapt the NPSA’s (2005) booklet for use in nursing education and training.
* A larger multi-centred study is needed to establish the national picture regarding students’ reporting of poor practice.
NHS employees have a responsibility for effective incident reporting. However, there is little evidence on student nurse practice (Healthcare Commission, 2007). While the implications of not reporting concerns are well documented (Laming, 2009), the negative experiences of those who have done so act as a deterrent (House of Commons Health Committee, 2009). Staff who have reported incidents have often been through local disciplinary procedures, which discourages such reporting.
Experience as a practice facilitator for a London PCT has shown how student nurses raise concerns over potentially unsafe practice they have witnessed, but have felt unable to report. If the NHS is to learn from error, reporting must take place. While robust systems exist for students reporting poor practice (NMC, 2008a), there is little evidence of their effectiveness.
With student numbers increasing in the UK and the pre-registration nursing programme currently under review (DH, 2008; NMC, 2008b), educators need to understand student nurses’ reporting culture. This is necessary so that systems and processes can be developed to make reporting easier (House of Commons Health Committee, 2009).
Management of incidents within the NHS has seen mentors caution students against speaking out on poor clinical practice witnessed in their fellow medics (Robinson, 2007).
This is a major concern as there are serious implications for patients if staff are unable to report unsafe practice (Laming, 2009). But despite the obvious need to report errors (NMC, 2008a), considerable under-reporting occurs.
A case reported by the Commission for Health Improvement (2000) highlighted the difficulties for students in reporting suspected poor practice, particularly surrounding the theory-practice gap in healthcare delivery. Students’ understanding of potentially unsafe practice can influence their decisions and may depend on values.
The nursing profession includes different fields with diverse types of intervention, training, prestige and characteristics (Rassin, 2008). This may make it difficult for student nurses who may be lacking in experience to make decisions on safe or unsafe care delivery.
Historically, the repercussions of reporting incidents have focused on individual responsibility, while ignoring systems that have made the error possible (Burkoski, 2007). It is nurses’ general understanding of regulation and legislation related to error which has created disincentives for quality, with staff becoming too frightened to report for fear of reprisal or persecution (Burkoski, 2007; Cross et al, 2007).
The fears of being labelled as a troublemaker, appearing disloyal and being victimised by managers and colleagues are powerful disincentives against speaking up about genuine concerns (DH, 2006).
The litigious public only serves to exacerbate this problem, with staff reluctant to follow reporting processes for fear of personal reprisal (Burkoski, 2007). The usual response to a serious incident is an intensive search for a human culprit (Cross et al, 2007).
A shift away from blame does not condone reckless or malicious practice, but will create a working environment in which greater feedback can be given when things go wrong (Cross et al, 2007).
While it is human nature to make mistakes, it is also human nature to create solutions and identify alternatives (Dunn, 2003). The emphasis on a cultural shift away from blaming individual practitioners when things go wrong is important in enhancing patient safety (House of Commons Health Committee, 2009).
Building a culture of safety begins with the response that organisational leaders generate when an error occurs (Burkoski, 2007). Where there are open safety cultures, reporting is encouraged in principle and by example, and can have a positive and quantifiable impact on organisations’ performance (DH, 2006).
Patient safety incidents are more likely to be reported in an environment that is open and fair (Milligan and Dennis, 2004). In many cases environments have not been created that motivate and inspire clinical and non-clinical staff working on the frontline (DH, 2006). Environments that are conducive to blameless voluntary reporting and error prevention are the hallmarks of safety culture (House of Commons Health Committee, 2009) and must be adopted by all within the NHS.
This research aimed to explore what influences student nurses’ ability to report potentially unsafe practice witnessed in clinical placement.
The study used a qualitative research design in a naturalistic paradigm and an interpretative phenomenological approach. This allowed data to be collected on student nurses’ perceptions of their experiences, to enhance understanding of the research issue.
Purposive sampling was used to ensure that respondents with particular characteristics were selected, to achieve information-rich interviews.Bowling (2002) warned that purposive sampling has been criticised as results may not be generally applicable.
However, it was felt important to obtain a representative sample of students from all three years of training to gain as much knowledge as possible about the research question. There may have been factors affecting students from different years of training, which may not have become apparent if this sampling method had not been used.
A total of six individual semi-structured interviews were carried out. Participants were one mental health nurse, three children’s nurses and two adult nurses. Four were second-year students and two were third years. No first years expressed interest in participating.
Relevant university heads of department gave permission for the branches of nursing involved in the study. Students were invited via a letter as per National Research Ethics Service (2007) guidelines. This was either handed to them when they met me to discuss participation or by a lecturer involved in recruiting students for their branch.
During the process of gaining ethical approval, it was decided that the study should use students based in inner London hospitals and not those doing clinical placements in my own area of work in outer London. While familiarity with participants may introduce bias, it is also possible that lack of familiarity may have limited the richness of data obtained.
I carried out the interviews in the university setting as students may have felt more comfortable in familiar surroundings.
Key questions were drawn from the small amount of available literature and were also influenced by the study’s aims.
The questions were:
* Could you tell me what your understanding of unsafe practice is?
* If you have witnessed potentially unsafe practice in any of your clinical placements, how have you managed the situation?
* Does anything influence your ability to report potentially unsafe practice?
* What is your perception of current practice in relation to reporting in practice?
* Would anything help your or other students’ ability to report potentially unsafe practice?
Content data analysis was used, allowing for subjective interpretation of data through the process of coding and identifying themes and patterns.
Content analysis pays particular attention to reliability and validity (Silverman, 2006). To ensure trustworthiness of data analysis, it was vital to return to a selection of participants and ask if the description reflected their experience.
Also, validity is enhanced in semi-structured interviews as respondents can be helped to understand the questions; interviewers can be asked to clarify points and they have the opportunity to probe for further responses (Parahoo, 2006).
Results and discussion
For students to recognise the relevance of any given situation, including poor care, they must have prior knowledge of or familiarity with that experience (Spouse, 2003). All students identified a common strand about what unacceptable practice was. For example, ‘Something that may bring harm to a patient, or something that may threaten their safety, it doesn’t necessarily have to happen, it can just be the risk’ and ‘Practice which is going to harm, or could possibly harm, future service users or a member of staff’.
Content analysis then identified four main themes. These were:
* The student–mentor relationship in clinical placement;
* Actual or potential support provided by both the practice area and university;
* Students’ own personal confidence and professional knowledge base;
* Fear of failing the clinical placement.
When students were asked what influences their ability to report, the following issues were highlighted:
‘The relationship that you have with your mentor because you can have a mentor that just seems very busy or uninterested or gets on with the rest of the team very well. If you felt like an outsider it would be very difficult to say something.’
The student-mentor relationship is crucial to learning experiences in clinical placements (Wilkes, 2006; Spouse, 2003). Where there were problems with this relationship, students highlighted that this had an impact on their ability to report.
To maximise learning potential, students need mentors who are approachable and accessible, both in practical and emotional terms (Wilkes, 2006). However, students raised concerns about the aftermath of reporting and the impact it may have on learning potential:
‘I’d worry that the nurse was going to retaliate against me…she may hold a grudge…she may think that I went above her, above her authority.’
Students were concerned about the remaining placement experience and of what staff would think about them if they reported:
‘I would worry about being thought of as a troublesome student nurse.’
Students look for inspiration from role models who demonstrate caring for patients and students (Papp et al, 2003). The study participants alluded to role modelling as being important to their learning: ‘I’ve never seen a qualified nurse report.’ Practice cultures such as this may be passed on from mentor to student (Twentyman et al, 2006).
This information obtained from all six students supports the fact that potentially or actual unsafe practice does or would continue to go unreported.
Students expressed concern about the support they would receive in practice if they reported:
‘If you reported, your mentor may not be as supportive anymore.’
This can impact on students’ overall learning from any clinical experience. Knowing that support would be there if they reported had a bearing on their actions:
’If we knew that we had support, not necessarily from the university…but actual support on the ward.’
This was raised as an issue by a number of students:
‘If we felt that the practice area was going to be supportive and listen.’
One student who had reported an incident related this decision heavily to the support received in placement:
‘When I reported I received a lot of support from the staff on the ward, I think a lot of this was because there has been little instances before and they had not reported them and they had had concerns, but obviously being a permanent member of staff it is a lot harder to say.’
This had an impact for this student’s future practice. However, readiness to provide this support did not exist everywhere:
‘The university and practice areas do not work together and unfortunately this affects the student’s confidence in both areas. This needs to be changed, to help support students who witness unsafe practice.’
In addition previous experience of the management of reporting had not always been favourable. Experiences in any environment can have an effect on the degree and type of learning that takes place, as well as a significant impact on how students are socialised into the nursing profession.
The need to belong has been identified as an important factor for students in clinical placements (Atack et al, 2000). Positive interpersonal relationships between registered nurses and students are fundamental to a clinical placement that facilitates belonging (Levett-Jones et al, 2007).
Mentors play an important part in promoting belonging with an emphasis on the quality of the student-mentor relationship determining whether or not they fit in to the clinical environment (Levett-Jones et al, 2007).
Students identified that it was important for them to feel part of the team in their clinical environments; if they felt detached from the team it had an impact on their ability to report:
‘There are some situations that I think are quite difficult to say things, it depends on how well you know the people on the ward, or the home setting or whatever or how well you slot in to the environment really.’
Students identified a gap in the support offered by the university while on clinical placements and identified individuals who they would feel able to report to:
’There used to be a system where the link lecturer went out and visited clinical placements on a regular basis and that has been stopped for some political reason in the university…now it is not happening I think that it could lead to a lot more problems developing.’
The ability to provide high-quality care is crucial to nurse satisfaction; nurses who provide poor care and have negative attitudes create job dissatisfaction for co-workers who want to provide good care (McNeese-Smith, 1999).
Patient care is no less important to nursing students entering the workplace. Environments with poor standards of care have a negative impact on student placement experience (Brodie and Inoue, 2005).
Confidence and knowledge base
Students were asked what would influence them in making decisions about reporting: ‘People’s backgrounds and how their ethics are and what their understanding is of the ethics behind the NHS and behind healthcare, so it really varies.’
Confidence is influenced by a number of factors including gender, age, religion and moral standing and these were not explored in this study.
Student nurses show great flexibility of thought, but they are not always able to articulate their anxieties, either about study or clinical placements (Spouse, 2003).Along with this lack of confidence comes the fear of what is going to happen. Students showed they were aware of professional accountabilities to report (NMC, 2008a). However, their reporting decisions would be swayed by a number of factors.
Students identified that confidence and previous experience are important factors in reporting; the full extent of participants’ previous experience was not addressed in this study, and is a recommendation for any further study:
‘You get students who obviously have more experience and know what is acceptable and what isn’t and in certain fields there are practices where you see something that’s done or not done and initially you make a judgement that it might be neglect. Then you realise that there may be a reason behind why something isn’t being done.’
‘I think the main factor is probably the student themselves, if they feel confident to do it.’
Registered nurses have highlighted how they are influenced in their decisions by the difficulty they have in using the reporting systems (Cross et al, 2007). This also appears to have an impact on some students’ abilities:
‘I think that the documentation that students have to fill out from the staff on the practice placements can influence students wanting to alert other staff or students or lecturers.’
Students highlight that their own degree of knowledge affects their abilities to report. While academic study underpins practice, nursing staff frequently qualify ward-performed procedures, stating that ‘real life’ situations use different methods to those taught in the classroom (Spouse, 2003). These instances challenge students’ assumptions and provide the impetus for further clinical reflective investigation (Spouse, 2003).
One student interviewed questioned some qualified staff nurses’ practice:
‘I’ve seen a couple of nurses who I thought were unsafe and I think that they wouldn’t know that they were being unsafe to be perfectly honest.’
As a student, questioning a qualified professional’s care delivery can be daunting. One student suggested they would have to consider all the implications of reporting:
’Is it worth the stress that comes with it by making it official?’
Failing clinical placements
There is little research exploring students’ feelings about their fear of failing clinical placements. Students identified this as a major consideration when deciding to report an incident:
‘We are kind of fearful because we want to pass our placements, we always feel like we will get in trouble’.
Students also showed concern about the aftermath of reporting and this also relates to assessment documentation sign-off. One student suggested:
‘If you were having trouble with your mentor, you may well be less inclined to report if you thought it was going to affect your final grades.’
The factors influencing students in their decisions to report are not dissimilar to those identified by safety agencies as barriers to reporting in healthcare organisations (National Patient Safety Agency, 2004). These include: fear of blame, particularly among junior staff; high workload; staff perception of the incident; lack of feedback; and lack of knowledge of what happens in the reporting process.
The NPSA (2004) identified factors that increase organisational learning in healthcare via reporting systems. These include: showing that changes resulting from reporting incidents do make a difference; involving staff and patients in developing safety systems; providing more feedback to staff; and developing an effective reporting system.
It would appear that some students would report potentially unsafe practice if the environmental factors were conducive. It is also evident that some students are not reporting potentially unsafe practice, influenced by a number of factors. Even though only six students participated in this study, it still indicates that unsafe practice is going unreported. This is especially concerning as government bodies say increasing numbers of staff are reporting poor/potentially unsafe practice (NPSA, 2007; DH, 2006).
It is time for the nursing profession to take stock of current organisational culture and practice and address issues around reporting in practice.
Participants identified that mentorship preparation needs to be robust and should explore student nurses’ need to belong in clinical placements. Students felt that if they reported they would be ostracised from the placement area.
Mentors need to be positive role models and students need open and honest experiences of reporting. This also needs to be addressed in mentor updates. The NPSA (2007) highlighted the importance of learning from staff who have reported when patients have or could have been harmed.
Patient safety has yet to be fully integrated into nurses’ education and training programmes (House of Commons Health Committee, 2009). This training should include the recognition that errors will inevitably occur in certain circumstances (House of Commons Health Committee, 2009).
There is scope to adapt the NPSA’s (2005) booklet, given to medical students, for use in nursing education and training. This emphasises how patient safety can be improved by effective teamwork, good handover practice and meticulous cross-checking. This also gives students the skills and confidence to speak up when they, or others, have made a mistake and provides an opportunity to look at errors made and actions taken to rectify them (NPSA, 2005).
A larger multi-centred study is recommended to establish current practice nationally.