El color y la comunicación

This first findings chapter presents an articulation of two dominant social logics – a logic of experientialisation and a logic of protectionism − that emerged from participant interview data and characterised patient involvement in practice assessment. The chapter starts by providing a brief genealogical synopsis of regulatory body standard requirements for service users and carers involvement in the assessment of nursing students’ practice. This is followed by a detailed analysis of each logic, illustrated with extracts from the empirical data. Finally, the chapter considers a third social logic, or more accurately a counter-logic, of systematisation that make visible the ‘marginal practices’ that have been subsumed by the two dominant social logics (Glynos and Howarth, 2007:194). The consideration of counter-logics allows for a fuller critique of patient involvement in practice assessment by examining actors alternative ideals and values, and demonstrates how different groups of actors’ have problematised or opposed patient involvement as a normative practice (Glynos and Howarth, 2007). Throughout the chapter, extracts from the empirical data will be used to illustrate the logics and the on-going struggles and tensions between vocation and profession.

A synopsis of the regulatory service user involvement requirements

In order to appreciate the patient involvement practices that these social logics represent it is helpful to provide a brief overview of service user involvement within nursing’s regulatory body standards. Since 1996 the NMC (formally the UKCC and English National Board [ENB]) had required HEIs to demonstrate service user involvement within all areas of curriculum development (ENB, 1996; NMC, 2004).

169 Although the ENB (1996) had advocated service user involvement in student assessment, it did not specify which type of assessment – academic or practice, neither was there any indication of whether that related to inviting individuals into the HEI to assess students or asking patients to assess students in the practice setting.

What has emerged from a review of regulatory standards following the creation of the NMC, is that the previous ENB requirement for service user involvement in student assessment was not adopted by the NMC in its subsequent 2004 revision of the pre-registration standards (NMC, 2004). Consequently, Mott MacDonald, the organisation commissioned to carry out course reviews on behalf of the NMC, continue to audit HEIs’ involvement of service users and carers in programme development and delivery on a biennial basis, but a review of their involvement in student assessment was notably absent (NMC/ Mott MacDonald, 2009). Interestingly, when the NMC published the 2010 standards for pre-registration nursing education, programme providers were again required to ‘make it clear how service users and carers contribute to the assessment process’ (NMC, 2010b:82), although, as with the previous ENB guidelines, the NMC did not specify the ways in which service users could contribute, whether this related to academic or practice assessment and in which context – HEI-based or practice-based. It was only later, in March 2011, eleven months after the publication of the first Francis report (Francis, 2010), that the NMC provided some clarification in an advisory document, ‘Advice and supporting information for implementing standards for pre-registration nursing education’ (NMC, 2011). The NMC constituted service user and carer involvement in student assessments as a ‘new requirement’, stating:

‘Programme providers must make it clear how service users and carers contribute to the assessment process. Being involved in assessment in a meaningful way, without placing inappropriate responsibility on them, can be challenging and, where service users and carers do contribute, the outcome

should not rest on their judgement alone. …….There may also be issues of validity and reliability of their judgements, which may cause anxiety for students. Notwithstanding these issues, many programme providers are beginning to find innovative ways of enabling service users and carers to make an effective contribution to the assessment of students.’(NMC, 2011:60)

Examples of new involvement activities included the use of hand-held electronic devices to record patient feedback; service user and carer testimonials; mentors approaching service users directly; involvement in HEI-based practice assessment such as OSCEs and service user involvement in the assessment of videoed scenarios (NMC, 2011). Despite these suggestions, there remained a distinct lack of clarity on what aspects of a student’s practice service users and carers were being asked to assess. In the above statement the NMC positions the programme provider in control, placing nurse academics in a dominant position with the power to enable service users and carers, rather than promoting a collaborative partnership approach.

The NMC’s revival of the now fourteen-year-old principles could be attributed to the normalisation of the patient-consumer subject position that reflected their constitution as healthcare consumers and partners in care. But it also could have been a reaction by the NMC to the negative publicity around the publication of the Duffy report (2003) that concluded some nurse mentors were not failing underperforming nursing students, as well as criticisms over the quality of nursing care highlighted within a number of reports from the Healthcare Commission (2006; 2007), Care Quality Commission (CQC, 2010; 2011), and the independent Mid Staffordshire NHS Foundation Trust inquiry report (Francis, 2010). All of these reports highlighted what appeared to be an alarming decline in standards of patient care, and a failure of health professionals to listen to patients’ concerns within UK hospitals. Unlike the Healthcare Commission and CQC reports, the personal stories recounted in the first Francis report (2010) were widely reported in mainstream media creating a narrative that health professionals could no longer be trusted to put patients’ interests first and

171 that nurses were no longer identifiable against a sedimented, vocational subject position where nurses had been constituted as ‘angels’, ‘caring’, and ‘kind’ (Ten Hoeve, et al., 2014). The NMC, possibly in an attempt to be seen to be in regulatory control, took action. By reintroducing service user involvement within practice assessment the NMC could be viewed as attempting to reposition itself as a responsible regulator and responsive public protector by reminding HEI nurse academics of the demand for service users to be included in the education of the future health workforce. Thus, potentially undermined the on-going professionalisation of nursing by instilling a discourse that the patient, not the nurse mentor, might know best. The consequence is that the nurse, is repositioned as a vocational construct, which becomes restricted to caring for the patient (as the patient sees fit), rather than operating as an expertly informed, evidence-based professional who may have a good (or even better) understanding of what might be in the patients’ best interest.

Social Logics

Practical-caring vocation and technical-scientific profession could therefore be considered as two social logics that characterise nursing as a regime of practices. The current debates surrounding graduate entry-level nursing and HEI nurse education are indicative of a hegemonic struggle that attempts to separate vocation and profession into two opposing constructs. An exploration of this struggle frames the whole thesis, however the thesis does not offer an analysis of these social logics specifically. Instead, the thesis is focused on offering a critical explanation of patient involvement in practice assessment as a social practice within a regime of nursing. Therefore, the logics of vocation and profession act as meta-logics that not only characterise nursing as a regime but also can be shown to envelop and influence the educational practices

that sit within that regime, including mentorship, patient involvement and practice assessment (Figure 12).

Figure 12: Vocation and profession meta-logics

As alluded to in earlier chapters, the tension between logics of practical- caring vocation and technical-scientific profession has helped to constitute patient involvement in practice assessment as a strategy to enable patients, as primary consumers of health services and associate consumers of nurse education, to influence and moderate nurse mentors’ professional judgement of nursing students’ practice. The assessment of students’ technical, affective and professional

Practice Assessment

Mentorship

Patient Involvement

173 competence is a fundamental part of pre-registration nursing education, therefore my analysis of the social logics pertaining to patient involvement considers the characterisation of involvement practices and examines the degree to which those tensions are reflected within participant narratives. On the surface, patient involvement might appear to be a sedimented practice, but rather than taking a surface approach to examine how and why this practice has become naturalised or contested, the use of logics enables an examination of the rules or grammar of that practice, and the ‘conditions which make the practice both possible and vulnerable’ (Glynos and Howarth, 2007:136).

Dominant logics

The dominant social logics that characterised patient involvement in practice assessment were experientialisation and protectionism. Experientialisation comprised a number of quality monitoring and assessment activities where patients were engaged in dialogue with mentors, students or lecturers with the intention of inducing a positive change in students’ caring behaviours. This involved consideration of patients’ subjective experiences and their experiential expertise being recognised and valued by those immersed in healthcare delivery and nurse education. The logic of protectionism consisted of various strategies actors employed to avoid risk, whether that be to themselves or others. The chapter now moves to consider each of these logics in detail.

Logic of Experientialisation

The social logic of experientialisation describes the dominant discursive patterns and practices that emerged from participant interview data, that positioned patients as experts by experience, best placed to assess the quality of nursing students’ care

delivery, especially students’ affective competence and vocational attributes. This logic privileged the patient’s position as a consumer of students’ practice where their engagement in a tripartite dialogue with the student and mentor was considered an effective strategy to induce behavioural and attitudinal change, instilling vocational values. Fundamental to this was the reciprocal exchange between the patient, student and mentor where each group of actors recognised the interdependence of their relationship during the assessment process, as the patient’s reliance on the student for their care was reversed as students became reliant on positive patient feedback during practice assessment.

Instilling vocational values

From the problematisation of nurses becoming too academic or ‘too posh to wash’, patient involvement as a hegemonic project aims to ensure that nurses understand and appreciate the patient experience. The demand for nurse education to concentrate on vocational values was characterised through a logic of experientialisation. By positioning patients as experts of experience, their feedback to students were considered essential for patient-centred nursing and to ensure the installation of vocational values, such as caring and compassion. Patient involvement as a mechanism to instil such values was articulated by a number of participants.

For example, Patient 4 (Extract 1) employed a gendered discourse to present a historic image of a vocational, female nurse whose most important attributes were feminised vocation-associated behaviours and gestures in preference to theoretical- scientific knowledge or technical skill. Extract 1 shows Patient 4 drawing from a logic of experientialisation to emphasise patient involvement as the best way to instil those behaviours. Students’ ability to develop nurturing or vocational behaviours were constituted as traits of a ‘super nurse’, traits that had a direct impact on how

175 Patient 4 experienced care delivered by the student. The assessment of vocational values was prioritised where the ability to convey patient-centredness was through non-verbal behaviours, ‘the little extras’ such as touch and eye contact. Here the personal relationship and interactions between the student and patient were considered essential in helping the patient ‘feel more cared for, more secure’, thus the emphasis was on humanising the patient’s hospital experience by recognising the subjectivity of the patient.

Extract 1

P4: It’s very much eye contact, tone of voice, the odd little gesture, be it verbal or touching your knee or something, you know … (Lines 681-619)

… it won’t be that you know I think she’s a super nurse she knows really what she’s doing, because I suppose in a way you almost accept that that is how it should be, it’s the little extra bits that make it so, make you feel more cared for, more secure, eh … more sure that you’re going to get out quickly (smiles), you know (Lines 630 – 633)

Extract 1 demonstrates a distinction between the patient’s expectations of hospital treatment compared to nursing care. Patient 4 appeared to accept a degree of objectification as a hospital patient within systematised institutional practices. Here systematisation refers to a number of managerial approaches where care is broken down into systematic processes in order to improve efficiency, cost effectiveness, service performance and patient outcomes (Close and Scott, 2008). There is a sense of acquiescence to this process ‘you almost accept that is how it should be’, yet the logic of experientialisation prioritised an expectation of an emotional connection with students and a need to feel cared for and safe in a situation where patients’ vulnerability is increased. This indicates a cake and eat it position, where the patient expected the nurse to be technically competent (this is how it should be) but also to be caring and compassionate (so professional and vocational). The gestures described

above are reminiscent of the moral virtues espoused by Florence Nightingale and suggest that the patient assessed the student against a norm of vocational nursing rather than against professionally defined competencies. In terms of the analysis of patient participant discourse, the image of a good or caring nurse constituted through a discourse of vocation was the discursive frame that dominated.

The following extract (Extract 2) reveals a contingent nurse identity illustrating a struggle between Patient 3’s acceptance of nursing as a practical-caring vocation and nursing as a technical-scientific profession. Again, the logic of experientialisation emphasised the patient assessor’s role in the installation of vocational values, where the patient assessed students against an image of a ‘good’ nurse with ‘a nice bedside manner’. This corresponds with Extract 1 to suggest that perhaps patients don’t really know what to expect from the nurse, because of the contradictory discourses that are also present. In contrast, academic study, historically constructed as a masculine activity, is presented as incompatible with good nursing, hence education is constituted as an obstacle or threat to a quality patient care experience. The hegemonic struggle between caring vocation and technical profession is made visible through the constitution of HEI-educated students as academically able but practically weak and potentially incapable.

Extract 2

P3: Yeah I think that it would be better if they spent more time with the people to know whether you’re actually capable of being a nurse kind of thing cos you know, you could study as far as you know, you could continue studying but it doesn’t mean you’re any good at what, like being good with people or having a nice bedside manner, you’d have more, more practice on patients, more time spent with them so they, you know that’s definitely what you want to do I think (Lines 280-284)

This may reflect the strength of political and media storylines that created a horrific fantasy of a technical-scientific nurse as opposed to a beatific fantasy of practical-

177 caring nurse. Despite degree pre-registration nursing programmes being available since the 1960s, the majority of patients, with the exception of Patient 5, who reflected on care provided by a male nursing student, still constituted care through a female-gendered discourse. The art of caring was seen as synonymous with nursing but for most participants being able to care was not enough, students were also expected to display a desire to care, foregrounding the experientialisation logic. Therefore, the idea that students may want a professional career with financial reward becomes incompatible with the construct of the vocational nurse.

Students’ reiteration of the value of patients providing feedback on their vocational values and ability to care for patients shows that the logic of experientialisation underlined the patients’ position as consumers of health services and nurse education (Extract 3). Student 2 drew on this logic to outline areas of their practice where they felt patients could contribute to the assessment process. The interpersonal dynamic between student and patient was considered an important element of care, where practice learning was constituted as a reciprocal exchange between the student, who assesses and provides care to the patient, and the patient, who assesses and provides feedback to the student.

Extract 3

S2: ... just your level of care really, whether you've done everything you should, whether you've respected their dignity and covered them up when they should, and talked to them properly and not talked down to them like a baby or child, whether you're friendly, whether you're happy, not miserable, you know things like that really, just … and whether they feel confident in your care really, you know, they were quite happy for you to give them an injection or ... or whatever you’re doing to them, that they’re happy with you providing that (Lines 421-427)

Extract 3 shows how patient involvement reminded the student of the subjectivity of the individual, rather than the patient being absorbed into a collective, objectified

group identity. The extract illustrates how the logic of experientialisation encouraged the student to adopt a person-centred approach to care and actively listen to the patient, attend to the patient’s feelings and experiences. The patient’s feelings and experiences of care were prioritised and show how a logic of experientialisation encouraged the student to focus on the manner in which they delivered care and how it was personally experienced by the patient. Nevertheless, extract 3 suggests a degree of normalisation of a practical-caring vocation image of nursing.

In contrast, in the following extract Student 4 appeared unsure as to whether vocation actually constitutes a good nurse.

Extract 4

S4: …care and compassion are very important I'm not saying it isn't, communication would be very, very important but I'd like to hear people talking a little bit more in nursing about competency not just care and compassion. Did you feel confident the student was fulfilling their role properly? Did you feel safe? Did you feel they had knowledge? Did you feel that they had read your notes and were aware of what your condition was and how it affected you? I would like to see that there. I don't want it just to be 'Did they smile and pat you on the shoulder?' and there's a fear that's what it would be reduced to and whilst that is the most important thing it's not everything…I used to think before I did my course, I thought I