Gastos: Servicios básicos

Students expressed concerns about their own future as a RN. The demands on the RN role and the numbers of acutely ill patients they would be responsible for was of particular concern to students. Such concerns have been identified within research into the emotional effects of role transition for newly qualified nurses and the consequences of feeling under­ prepared for the reality of practice (Boychuk Duchscher, 2009; Cleary et al., 2009). Students witnessed RNs rushing around and cutting corners, and alongside this they saw a fear of litigation should ‘something go wrong’.

Numerous open and in vivo codes were identified during the coding of transcripts and were brought together into substantive codes. Each substantive code was analysed and four of these were brought together into the selective code ‘feeling concerned about own future role’ (figure 8). Each of the substantive codes within this selective code is discussed below.

Feeling concerned about own future

role

Time pressures Accountability Uncertain future

jobs market the transition to RNFeeling ready for

Figure 8. Substantive codes within the selective code ‘Feeling concerned about own future role’

8.5.1 Time Pressures

The students expressed that when they qualified, they wanted to continue to spend time talking to patients, getting to know them as individuals in order to practise with empathy and compassion to meet patient's needs and relieve their suffering, and yet they saw RNs not having the time to do that due to role and organisational pressures:

In our lectures they say if you ever have nothing to do, then go and talk to a patient... I am kind of relishing this time because I know once Tm qualified I won’t have so much time with them (patients). (P1)

The students were aware that their ‘supernumerary’ status afforded them more time than would be available once they became RNs:

I can do an admission and it takes me half an hour and the nurse is breathing down my neck saying aren’t you done yet? They say you’re going to have to learn to hurry up. (P13)

Students did not differentiate between their taking time to do things properly that could save time in the long-run and their taking time because they were learning. However, students recognised that the change to RN status and loss of being supernumerary would affect the amount of time they had for all their responsibilities. Students particularly identified the limited RN time for talking to patients and this left students uncertain how they would

manage to individualise their practice. However, students also identified that different nursing practice specialities or clinical areas had differing time available for individualised and compassionate practice:

I expect it (time available for individualising care) to change, sadly enough I do expect it to change although I am hoping it won’t change. But in reality you can’t give one to one care to be honest, unless you are in ITU. Not in a ward setting it’s quite a shame really. (P11)

Students were aware of the risks to the ideal of individualised nursing practice. They could identify some pressures on RN practice that challenged professional ideals and could see that this might eventually impact upon them when they were the RN with the responsibilities:

It (paperwork) makes them (RNs) very busy and impacts on their level of care. There is so much to do and you have to squeeze it into a short space of time... it is a big possibility that it will affect the way I render my services in the future. (P15)

Interestingly some students also identified that time pressures had effected some of their peers, with ‘rushing’ and getting into ‘bad habits’ identified as risks that came with increasing responsibility and expectations:

I (second year student) spoke to a third year... and she said when we were bathing a

patient ‘Oh I miss doing this’ and I asked her what do you mean and she said 7 miss

taking time and doing stuff with patients rather than rushing... Tve got into bad habits... just getting the job done’. (P3)

Some students identified that as student nurses neared the end of their 3 year programme they took on more of the expectations of the role of a RN and with that came increasing pressure to behave in the same way, despite their ongoing supernumerary status. The students were identifying socialisation among peers in what some saw was the role and behaviour of the RN: rushing, cutting corners to get jobs done, and spending less time with patients. This change in a student’s approach to nursing care as they progressed through their education programme had been recognised in previous studies (Smith, 1992; Mackintosh, 2006; Maben et al., 2007; Murphy et al. 2009).

8.5.2 Accountability

Students expressed awareness of the change in accountability when they became a RN (NMC, 2008) and that accountability implied that making a mistake could result in ‘being sued’ or the threat of litigation (Cooke, 2006). This fear of litigation appeared to be a concern in relation to their future RN role:

I think there is a big difference from being a student and not being accountable. I know you are accountable for your actions but not being like legally accountable... if you (when qualified) mess up the drugs or if you do anything wrong, it’s kind of your head on the chopping block. (P1)

The fear of litigation was seen by students as the reason for so much nursing paperwork, the need to document everything to 'cover their backs':

I think that is the sad thing about the paperwork now, that if you don’t do it your back’s not covered... I mean I’m a student and Tm nineteen and thinking about getting sued... it’s quite scary. (P3)

The paperwork was like a double-edged sword, required for ‘covering their backs’ yet taking them away from their patients. Their fear of being sued required managing while they interacted with patients, so patients were not aware of this distraction and they could attend to their patients’ needs, an example of their emotional labour in nursing. Although students accepted the need for professional accountability, they felt quite concerned about its impact on the day to day expectations of RNs working within busy environments.

8.5.3 Uncertain future jobs market

In addition to these many factors impacting upon student socialisation, the current UK change to a nursing profession that had all degree entry was of concern to some of the diploma students, wondering how they would compete with other students or qualified staff who had degrees when applying for jobs. They wondered whether their diploma qualification would still be valued in the future:

move onto a degree when you qualify, like if I qualify with a diploma and my friend qualifies with a degree, are you going to have a job you know? (P1)

On the other hand, the degree students welcomed this change and saw the standardisation of qualification at degree level as helping the status of nurses and the future of nursing, in line with the NMC view (NMC, 2009a). The standardisation also put all UK student nurses on a level playing field in terms of expectations and would be more ‘fair’;

I do think it will be good to have everybody at the same level (degree) because me doing the degree ievei... I will get the same job... So I think reducing that difference in the level of the education might be a very good idea. (P4)

The future was full of uncertainty for many of the students, with many identifying the current economic pressures on the NHS as being a worry in terms of job availability when they qualified:

You worry about getting a job when you qualify because the NHS is cutting the jobs (P1)

I don’t know what jobs are going to be around, this year everyone has found it quite hard to find a job. (P8)

These concerns were frequently expressed by the participants and were important aspects to their future planning, particularly the potential to ‘have to take a job anywhere’ to launch their career. The students’ perceived ability to choose a job in an area or speciality of nursing practice they desired seemed to be diminishing within an economic climate of ‘cutbacks’. Such sentiments added to their concerns about their ability to engage in compassionate practice when they acme a RN as they saw themselves having to get employment in ‘busy wards’ where individualised nursing was compromised by the environment of ‘rushing about just to get the jobs done’.

8.5.4 Feeling ready for the transition to RN

Feeling fully prepared for the role of RN was another area of concern. As previously discussed, students understood that RNs have more complex and managerial responsibilities than those of the HCA and yet also felt their placement experiences or

working alongside HCAs had left them uncertain about what they should be doing. The confusion in a definition for the RN role appeared to be of real concern to them and their preparedness for becoming a RN, as these two students illustrated:

There are health care assistants who are doing washing, bed baths, and I am involved in those tasks as a student nurse and I am also involved in things like seeing blood taken, injections and those tasks... Td like to be more experienced (in those RN tasks) by the time I qualify. (P4)

We’ll be more a manager for that person’s care rather than directly the person who gives that care... the nurses (RNs) are allocating tasks to people (HCAs) who are not as well trained as them... if something as simple as a wash needs doing, the nurse won’t have time to do it, the HCAs will go and do it, but that’s what the nurse should be doing. (P5)

The transition to RN status was something they could not easily envisage, they did not feel their practice experiences had fully prepared them for the RN role. On top of this they were uncertain in what it was a RN was supposed to be doing, the reality of their learning did not match the professional ideals of the role. Such expressions further illustrated the students’ confusion and concerns about the comparative roles of the RN and the HCA, and dissonance between professional ideals and practice reality.