Taller nº 2 para padres e hijos

The students in the focus groups and subsequently interviewed remain convinced of their positive role in improving healthcare in the future - echoing the opinions of the first year students:

Yr2 Int2 ‘They are trying to get us to be the nurses of the future...that is the idea that we will change practice’

Yr2 FG2 A ‘but that is the thing, we are like... they are training us up to like report everything’ B ‘it is the nurses of the future isn’t it’

Int1 ‘It feels like the management of the hospitals have said to the uni - ‘this is what we want’ and they are trying to produce it but they are not, like, exactly writing everybody else off - but they are saying ‘well they are stuck in their ways now’

There is an appreciation of the difficulties of making this view of the future a reality; and the length of time and effort that it may take. This recognition is coupled with an awareness of the negative implications of the necessary changes for the current nursing workforce:

FG2 ‘we won’t ever change how people are in there... They will have to leave before the new generation. They won’t ever change. You can’t tell a band 6 to change her ways she won’t change’

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FG2 ‘... Like if nobody is wearing gloves.. for something that you should wear gloves for and you are putting on gloves you are the only one putting on gloves - it makes you feel like you are being silly (yeah or that you are wasting time) and you feel like everyone is looking at you thinking ‘What’s she doing?’ - you know you are made to feel that you are the one who is being over the top. Even though you know you are the one that is in the right. It is like being a Dudley do Right like you just said, that is what we feel like we are all of the time’

Communities of practice and their members can be reluctant to change or accept innovation if they are majorly focussed on the interests of those who are entrenched in established practices and also benefit from maintaining the status quo. The students therefore express concern that they may be negatively influenced by those individuals already established at the centre of their communities. They do however remain determined to withstand such negative changes to their attitudes and their practice:

FG2 ‘So give it another 10-20 years when the older ones have retired... we should reshape it. As long as we don’t get influenced by the workforce culture’

Such comments hint at a recognition that it is wrong to assume that all established nurses have differing values and less of a caring attitude. Some students clearly identify that access to the history of a community as personified by some of their well-established colleagues is an integral part of participation in that community and any related identity development. As articulated although this access may be in some way second hand or vicarious, as the student often simply witnesses rather than participates, there is an appreciation that at least some form of access is necessary if it is to be made part of their identities.

Similarly despite participants generally indicating their desire for change and their view of themselves as ‘new nurses’ it is not necessarily true that new students are inevitably more progressive than more established colleagues. Attempts to ‘fit in’ may necessitate that students have an equal investment in continuity - making the necessary connection with history more likely and thereby reducing their vulnerability and making their participation easier and quicker.

However some students view retaining their principles of practice outweighs their desire and ability to fit in:

FG1 ‘I know some wards that name the patients after the number of the bed like ‘oh I’m going to see bed 14’ and I know another ward that names all the patients by their names and I like it that they call them by their names...I’m hoping that I won’t become like that and I will stick to like, you know, like I have done in the first place’

FG2 A ‘But then again it is different but we know we have been taught properly so we know that we will never be like them’

141 B ‘Yeah’

C ‘we have seen their bad habits but we are not actually picking up on them’ FG2 ‘they want us to follow their bad footsteps like leaving medication out, the keys

everywhere you can’t do that - we have not been taught how to... I once ended up having a row and after that they were just funny with me because I stood my ground...’

Being ‘funny’ with an individual following the highlighting of less than optimum practice is an example of the climate that can be identified as an influencing factor on nurses’ decision to raise concerns - as this context of potential retribution can create self-doubt about whether speaking out is the ‘right thing to do’ (Jackson, et al., 2011; Laschinger, 2010)

Just like students in the first year, second year students still retain a view that the provision of learning opportunities whilst in practice is qualitatively different when supported by mentors and other clinical staff who have worked in those environments longer and/or who trained longer ago. Although there appears to be limited knowledge or understanding of the historical context of the previous provision of nurse education, students nevertheless feel this effects their experience for several reasons. They perceive that greater insight, understanding and empathy is shown by mentors who have had a more recent educational experience themselves:

FG1‘The ones I’ve worked with are slightly younger mentors so they are not really far out of education either so they understand you’

FG3 ‘ ... and if they are younger and qualified less time they know more about what to learn because it’s about what they wanted to learn’

FG1‘I think the courses have changed, well they have to don’t they? They do end up

changing... like people I know who got qualified not that long ago - it was only a foundation so they are back at uni trying to get the degrees and things, doing the modules - and so those ones who are the mentors are good because they are busy doing the uni stuff so they kind of get it’

FG1 ‘yes I think a lot of the older nurses, not older nurses but the ones that learned on the ward - they didn’t have to come to uni or anything like that they all say ‘what do you need to go there for to learn about nursing you need to be here doing it’’

Experienced nurses, not least those older and perhaps approaching retirement, possess practical experiences and extensive clinical skills which would be a valuable source of knowledge, acumen and insight for the students. However the current nursing work environment can often be characterised by perpetual challenge, high patient acuity, debates about safe staffing levels, inflexible shift patterns, excessive targets and reducing opportunities for professional advancement (Laschinger, 2010; O’Brien-Pallas, Tomblin-Murphy, Shamian, Li & Hayes, 2010). All these factors can result in a change in attitude and increased stress in established staff - a phenomenon that was recognised by the students (Lim, Bogossian & Ahern, 2010):

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FG1 ‘...they have been on the ward for 30 years they are not necessarily a positive influence... and the ones that are a bit fresher into it even if they are a bit older but quite newly trained they’ve still got that sort of drive.’

FG1 ‘I know some that have worked with have complained about their job but they have been there for like 30 years and I’m thinking well if you really don’t like it why don’t you do something else. I didn’t say that to them obviously (laughs)’

In a small (n17) pre and post intervention, mix method study in the USA, Bishop (2013) found that investment, in the form of a 3 day retreat, in a group of nurses, over forty-five years old who had been practicing clinically ‘at the bedside’ for more than five years, resulted in a ‘reawakening of the spirit of nursing’. They recognised and accepted that their focus on the ‘true needs’ of the patient may have become lost and resulted in increased work engagement, vigour and a changed view on caring for patients and their families (Bishop, 2013). It is acknowledged that this research is limited to a small voluntary sample of older nurses from one community hospital in USA.

There is mounting evidence of an association between symptoms often described as ‘burnout’ and different age groups of nurses. While many studies indicate that a proportion of nurses are considering or intending to leave the profession - numbers which can vary significantly among countries: from 4 to 54% (International Council of Nurses, 2012) this phenomenon may not necessarily be most widespread in the groups that the students in this particular research appear to believe (Leiter, Price & Spence Laschinger, 2010). For example, there is also significant evidence of attrition or intention to leave of newly qualified nurses with one explanation being that new graduates, as part of a younger generational cohort, may experience dissonance between the environment in which they were educated and the professional setting that they subsequently experience (McNeese-Smith & Crook, 2003). Such groups have significantly different expectations of occupations, different expectations of social norms and career expectations and aspirations than previous generations and the pattern may suggest that younger nurses may find the current healthcare workplace less apt to fulfil their career aspirations than previously.

So although the perceptions of the students, in all years is that it is the more established staff that appear to have lost idealism and aspects of ‘caring’- some of the literature may conflict with this viewpoint.

However there is also some supportive evidence that indicates that two of the primary drivers of burnout are: excessive workload and conflicts of personal values with organizational values (Leiter et al., 2010; Leiter & Shaugnessy, 2006). Examples of such conflicts in values are

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represented by the students when they frequently speak of witnessing less than optimum practice on their placements. However the students provided account of several registered nurses also appear to recognise that they have changed and identify their former selves in the students’ determination to care, maintain high standards and retain enthusiasm. They recognise this shift in their own identity and openly discuss those changes with the students themselves:

FG2 ‘So obviously it puts you in a difficult position because it’s like these things might not be, so to speak, bad enough that you like need to ring a bell - so to speak - but they are a bit concerning and a bit disheartening especially when people say to you ‘Oh I used to be like you all caring but now I’m not’’

FG2‘’Oh I used to be like you’ - but it is not a good way for a mentor to be when you are kind of learning off them and they are guiding you’

It would be wrong to assume that no established nurses welcome the potential offered by engagement with the new generation of students or indeed disinvest themselves from the future. However the students’ experience of some of the attitudes and behaviours of their established colleagues seem to still cause some confusion of what might constitute a good nurse; despite the students’ apparent developing recognition and evolving insight into what it means to be a nurse generally:

FG1 A ‘I think as well you need to be a people person there are so many that you go - bloody hell!’ (shakes head)

B ‘Yeah no bedside manner’

A ‘yeah they are useless, they are still good at their job but not right good with patients.

There are a lot like that’

It appears that the students are still reluctant to be too critical of their colleagues and remain keen to allow the possibility of a nurse being ‘good at their job’ even though their treatment and relationships with patients might be perceived as minimal or even poor.