The findings of this study found disempowerment and incivility within the clinical learning environment were experienced (see section 4.3.2). These findings support Daiski (2004) study where he found that nursing students craved affirmation and praise for their contribution. In the present study, many students verbalised their vulnerability and the difficulties they experienced trying to fit into the nursing role and profession. Low self-esteem is commonly associated in the nursing profession and is also associated with oppression and professional socialisation, according to Mooney (2007). Mackintosh (2006) in a study of how nursing students care, found that in order to be socialised nursing students reported caring less in order to be accepted more into the ward.
Oppressed group behaviour is not a new phenomenon in nursing and was described by Freire as far back as 1970’s. In respect of this Freire (2000) theorised that the oppressed self-loath and suffer low self-esteem, and that in order to feel better and be successful, they develop the characteristics of the oppressor. The influence of preceptors was such that through imitating their behaviours, whether positive or negative, the nursing students began to feel as if they belonged. Randle (2003b), reported in a study of nursing students’ self- esteem, that preceptors have the most influence on the nursing students. She acknowledged that occasionally nursing students may feel pressurised into suppressing their beliefs in order to be accepted.
The impact of the historical legacy on nursing, and an apparent continuation of a hierarchical type of culture in the profession, continue to have an impact and cannot be dismissed in light of the findings of this study. The impact of an oppressive culture in this study impacted participants’ experience of the clinical learning environment and was disempowering. This culture, if unchallenged, facilitates qualified staff to behave in this manner and may lead to situations where incivility becomes acceptable and normal and is therefore accepted by staff or students. It is interesting to note that more contemporary research highlights these “hierarchical relationships”, reported by Duchscher and Myrick (2008) and Hollins Martin and Bull (2010) prevail in nursing and midwifery to this day
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(Canadian and UK studies respectively). The capacity of nursing students to question such behaviours is fundamental to driving change within the clinical environment and needs to be promoted through education of staff and nursing students. It was evident in this study that nursing students did not wish to question behaviour preferring to get through placement and pass. Timmins and McCabe (2005) found that when nurses acted in an assertive manner, it appeared to conflict with expected and societal norms of a “caring nurse”. It was a concern in this study that nursing students described adapting without question to their preceptors behaviour. This raises a legitimate concern which is are nursing students so anxious to fit into the workplace that will they focus on pleasing and conforming, rather than questioning and querying.
Hollins-Martin and Bull (2010) found in a study of registered midwives that socialisation in nursing/midwifery culture involved acquiescence to the hierarchy and furthermore noted that conforming behaviours are commonplace. The nursing students were not aware in the present study that such conformity and acquiescence may continue once qualified. This conformity and lack of questioning is the antithesis to critical thinking and questioning practitioners that are required in the current health care system. It is imperative that nursing students learn to critically appraise information in order to be capable of responding to the challenges of healthcare in the future. Preceptors and educators need to be aware of this type of conformity and encourage nursing students to be assertive and independent thinkers.
Campbell (2003, p. 423-426) suggested that though many aspects of nursing have changed through the years, the one constant is nurses’ poor treatment of one another. Roberts et al. (2009, p. 290), however, refer to this culture simply as “lacking in support”. The findings of the present study support other contemporary literature (Campbell, 2003; Randle et al., 2009a). Smith (2014) supports the aspiration of empowerment in education and practice through nurses being more respectful of each other, and advocates that individual differences are recognised and respected. Nurse-to-nurse discrimination and oppression demonstrates the lack of empowerment in nursing, according to Smith (2014). As indicated in section 4.3, evidence from the present study suggests that the culture in the
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clinical learning environment for nursing students can be challenging, and incivility towards nursing students was present. Roberts et al. (2009) researched oppressed group behaviour in nursing, and found that nurse managers can improve these behaviours and improve the culture within the workplace. A concerning finding with the present study was that some nursing students described how challenging they found the culture, and its resultant impact on them. Nursing students referred to feeling as if they were “drowning” and feeling like a burden (section 4.5.3). Culture however also impacts patient care: Findings from the present study demonstrated that empowerment of preceptors and managers impacted empowerment of nursing students (section 4.3.2). Further evidence of the importance of culture was endorsed in the Francis report into Mid Staffordshire Trust hospitals (House of Commons, 2010) that demonstrated the importance of culture to patient safety according to Scott et al. (2014).
“This breakdown in nursing care and professional nursing culture had a profoundly detrimental effect on patient care, leading to basic physical and psychological neglect of very vulnerable patients, loss of dignity, distress, injury, and in extreme instances it led to patients’ death.” (Scott et al., 2014 p. 8)
Therefore culture and its relationship with patient care is a very important and significant predictor of safety within a hospital. Organisational/hospital/ward and unit cultures that encourage critical thinking, questioning, new ideas and creative solutions are needed. The presence of nursing students in the clinical learning environment should bring change and innovation to the clinical learning environment. Stifling cultures smother and extinguish the drive for change that students bring. Nursing literature documents many accounts of deficits in the clinical learning environment, as experienced by nursing students, and this is supported by the findings of the present study (Chan, 2002, Papp et al., 2003; O’Driscoll et al., 2010; Sabatino et al., 2015). In the present study, this was seen in how the nursing students viewed themselves being aware of where they were situated within the hierarchy, and wanting and striving to be treated equally. This was further compounded by a feeling of gratitude and appreciation towards those who were interested in teaching and provided support to the participants as they learned (section 4.4.2). There was no sense of entitlement or expectation on
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behalf of the nursing students that this was the way it should be. This is perhaps further proof of the issues concerning self-esteem in nursing students that support the findings of the present study (Levett-Jones & Lathlean, 2008). What is concerning in the present study is that nursing students did not view the behaviour as maltreatment, but had actually accepted and normalised it. The question needs to be asked: if nursing students fail to experience care and empowerment during their training, can they demonstrate such behaviours and attributes once qualified?
A concern in the present study was that participants on some occasions described being poorly treated and subject to what appeared to be unreasonable behaviour by qualified staff. One nursing student in the present study described occasions of being criticized and verbally abused, or as she termed it, being “put down” in front of others (section 4.3.2). It is also of concern to note that while the term “bullying” was not used directly by participants, an environment of conflict and incivility was described by some, supporting a previous study finding by Randle (2003a). This type of behaviour, if repeated, may lead to bullying, or if allowed to continue or go unchallenged, could have damaging effects on nursing student empowerment. Bullying is defined by Cooper et al. (2011, p. 2) as:
“long-term aggressive or negative acts or behaviours, carried out repeatedly over time, and directed at someone who finds it difficult to defend him/her self because of a relationship with the bully that is characterised by an imbalance of power”.
The participant in the present study did not refer to this behaviour as bullying, nor did she state that she felt that she was bullied. However, if allowed to continue unchallenged the repetition of this type of behaviour may result in bullying. In addition it is possible that acknowledging the literature on incivility towards nursing students (Shanta & Eliason, 2014) even if the nursing student did feel bullied she/he may not report it. Roberts et al. (2009) described bullying as belittling and downgrading others, impacting both self-esteem and job satisfaction, and suggests there is a paucity of research into the subject in nursing (Randle, 2003a). Supporting this definition, Daiski (2004), Roberts et al. (2009) Laschinger et al. (2010b) and Thomas et al. (2015) describe a culture of incivility and conflict in
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some nursing environments. “Civility” is defined by Clark and Carnasso (2008, p.13) as:
“…an authentic respect for others when expressing disagreement, disparity, or controversy. It involves time, presence, a willingness to engage in genuine discourse, and a sincere intention to seek common ground”.
Civility is a foundational aspect for professionalism, according to Shanta and Eliason (2014). There was evidence in the present study of episodes of incivility and behaviours that nursing students found difficult to contend with. The impact of this environment may have long-lasting effects on nursing students. Thomas et al. (2015) in a study of 26 nursing students outlined how nursing students struggled to cope with incivility in the clinical learning environment. Lash et al. (2006) found that verbal abuse of nursing students while on placement made them consider leaving the programme, and many of these types of incidents went unreported. While, Daiski (2004), in a Canadian study, found that lack of support and respect for each other in healthcare settings was common amongst qualified staff, and was perceived as being particularly focused at degree educated staff.
Many research studies have documented the long trajectory of incivility within nursing culture (Randle, 2003a; Roberts et al., 2009; Gillen et al., 2009; Laschinger et al., 2010b; Laschinger et al., 2016). However, both a supportive clinical learning environment and incivility in the nursing culture were experienced by the nursing students in this study. Nursing students in this study were disempowered when they experienced incivility and poor behaviours within the clinical learning environment. This proved to be very challenging for them and they articulated how they felt when they experienced this poor treatment (section 4.3.2). The findings of the present study echo the findings of other research (Randle, 2003a; Daiski, 2004; Gillen et al., 2009; Shanta & Eliason, 2014) in finding an oppressive type of culture that could and should be doing more to welcome nursing students in order to ensure that their clinical learning experience is positive and empowering.
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It would appear, therefore, from the findings of the present study and in consultation with the literature that the clinical learning environment remains challenging for nursing students, who depend on their clinical placement to learn from role models/preceptors on how to provide nursing care. The expectation is that within the clinical learning environment positive behaviours and supports are available (Sabatino et al., 2015). It is important, therefore, that if behaviours and environments are challenging and incivility is present in the clinical learning environment culture, that a change is required.
Concluding thoughts on cultural influences
The challenge in nursing education and practice is to provide quality and compassionate care to patients and to demonstrate this to nursing students during their time on clinical placement in order that they will learn to emulate. However, it is unlikely that it is possible for nursing students to witness best practice within a hierarchical and oppressive type of culture. This study supports both the literature and anecdotal evidence that culture in nursing can be challenging. Emanuel (2013) suggested that in order to address these challenges of an oppressive/hierarchical culture, as presented in (section 4.3) nursing students need to be empowered and supported in clinical practice. Conformity and acquiescence should no longer be acceptable or encouraged in nursing. A suitable candidate for nursing is one who asks questions and retains a spirit of inquiry, which may mean not conforming to rituals and customs. It is important therefore to ensure that the learning environment where nursing students are placed for the clinical practice component of their nurse education is an empowering environment, and that staff are aware of the impact of their actions on nursing students’ empowerment. Nursing students should and need to be facilitated to question; self-esteem needs to be nurtured and conforming behaviours by nursing students contested. In order to do this the culture in nursing needs to change.
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