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Tensions experienced by student nurses in a changed NHS culture
Article
Tensions experienced by student nurses in a changed NHS culture Ann Wakefield
The ideas for this paper were generated supplementary to my undertaking a wider investigation examining what it was like to be a surgical nurse. The study followed the clinical development of four student nurses and subsequently analysed how they managed their role within the ward. From observations, a series of operational tensions or pressures extant between specific members of the ward team were identified. These tensions were seen to manifest either because students felt ‘undervalued’ or akin to ‘a spare pair of hands.’ For this reason, students directed many of their ‘negative’ comments towards health care assistants, as they felt this latter group of staff were ‘taking away’ their role. Conversely, health care assistants were observed directing their own frustrations towards student nurses, who were perceived as inefficient, uncaring or devoid of clinical skills. © 2000 Harcourt Publishers Ltd
Introduction
Ann Wakefield PhD MSc RGN RMN RNT Cert Ed, School of Nursing Midwifery and Health Visiting, The University of Manchester, Coupland Building 3, Coupland Street, Manchester, M13 9PL, UK. Tel: + 44 (0)161 275 7007; Fax: + 44 (0)161 275 7566; E-mail: ann.b.wakefield@ man.ac.uk Manuscript accepted: 23 February 2000
The wider study forming the basis for this paper examined what it was like to be a surgical nurse working within the UK’s contemporary National Health Services (Wakefield 1996). The study itself was grounded in ethnomethodological philosophies (Garfinkel 1967). In other words, I was interested in making sense of the routine practice of nursing, by examining to what extent nursing actions were features of the nurses’ everyday affairs (Cuff et al. 1992; Garfinkel 1967; Kelly 1998). During the study, it was possible to simultaneously identify a series of operational tensions extant between student nurses and other members of the nursing team, in particular health care assistants. Hence, it is intended to examine this latter element in more detail within the following discussion.
Study method Accession of data for the study was achieved via a series of field observations. These observations took place over a 4-month period within one
© 2000 Harcourt Publishers Ltd doi:10.1054/nedt.2000.0467, available online at http://www.idealibrary.com on
general surgical ward in the north of England. This data gathering technique involved me working alongside 22 permanent nursing staff and four students, a process that facilitated my ability to become actively involved in the work of the ward. As a result of engaging in what ethnomethodologists term watching and listening, it was possible to understand the setting in more detail (DePoy & Gitlin 1993). Hence, I was able to gain a more comprehensive understanding of the relationships between staff as a result of having established and sustained a many-sided relationship with the subjects being observed (Lofland & Lofland 1984). This notion of many-sided meant that I participated in the work not just as a surgical nurse, but also as an educationalist, a researcher and a colleague. To underpin these observations, a series of field notes were documented at the end of each shift (Wakefield 1996). In effect, these data gathering processes reflected Fetterman’s (1991) description of an ethnographic inquiry in which he states: The ethnographer is a human instrument. Relying on all its senses, thoughts, and feelings, the human instrument is the most
Nurse Education Today
(2000) 20, 571–578
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Tensions experienced by student nurses
sensitive and perceptive data-gathering tool. This process of observing, participating and reviewing the fieldwork notes became the basis of the data gathering and data analysing process in its own right (DePoy & Gitlin 1993). Nevertheless, the aforementioned actions were strengthened and underpinned by data extracted from my own practice, which had been amassed over what was then a 15-year period both as a surgical nurse and nurse educationalist (Wakefield 1996). This type of data is semi-autobiographical in that it draws predominantly on the life of one individual – namely myself (Cotterill & Letherby 1993). Nevertheless, because both the field notes and autobiographical reflections were in effect documentary illustrations of the lives of many people, they too became essential features of the ethnomethodological framework used during the study. Although it could be suggested that such methods are not readily generalizable to the wider nursing population (Cotterill & Letherby 1993), it does not mean that this type of data should be disregarded. Harrison and Lyon (1992) support this view, arguing that such data allow the private and personal worlds of both the researcher and the researched to be brought into the public domain. This is particularly true for student nurses, especially as many of their concerns may not be voiced within the wider nursing arena. Although the above approach to research raises some ethical concerns, Lofland and Lofland (1984) suggest that when researchers are engaged in the covert observation of an ‘open’ setting such methods can be justified. Despite this assertion, it must be acknowledged that a ward cannot be considered a communal access zone. However, as the observations for this study were undertaken while working with students, a type of behaviour considered authentic, I felt more than able to defend the use of this method (Wakefield 1998). This latter point is particularly important, given that many of the comments relating to the issues discussed here were ‘off the cuff’ remarks, which were unlikely to be made if the students thought they were being ‘targeted’ for information. Baker (1978) would contest the above point however, stating that: If the researcher manages to avoid being unmasked during the time (s/he) is acting as a complete (concealed) participant,
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(s/he) inevitably betrays (her/his) former workmates when (s/he) reports on the research. Despite this, Roth (1962) asserts that it is impossible to gain informed consent from all those from whom data will be collected when investigating public domains such as hospitals. It must be emphasized however, that during the study I was not seeking to deceive the participants as Johnson (1992) suggests in his text A Silent Conspiracy. Instead, I felt that by employing the above methods the students were able to continue with their work unhindered, enabling them to paint a picture of the ward as they perceived it to be, without prompting or bias.
The organizational hierarchy When student nurses enter the ward at the start of their period of clinical practice, they manifest as ‘unknown quantities.’ At the outset of a student’s period of practice, qualified nurses do not always know what the student can and cannot do. For example, a ward might be required to mentor students from a variety of educational programmes each demanding that different needs and learning outcomes be met by the end of the practice period. For this reason, at the outset of the allocation nursing staff need to ascertain the extent of the student’s clinical competence. Within this framework, the notion of an organizational hierarchy is created, given that qualified nurses are able to exert dominance over the student on account of their perceivedly ‘superior’ knowledge (Freidson 1988, Wakefield 1996). This concept also reflects Freidson’s (1970, 1988) notion of professional dominance. When defining what he meant by a hierarchical division of labour within medicine Freidson (1988) stated that: All occupations in the (medical) system are given less prestige than the physician by society at large … Furthermore, there is a hierarchy of prestige and authority among paramedical workers, with nurses for example being higher than attendants and technicians. During my own study it was possible to observe similar processes to those outlined above
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being instigated as a means of reinforcing the ward’s overt divisions of labour, in which trained staff were seen as having more prestige than support workers. In other words, registered nurses were perceived to be at the apex of the hierarchy given they were able to complete their work with a high degree of ‘functional autonomy’ (Freidson 1988). The term ‘functional autonomy’ is defined here as the extent to which a worker can carry out a task without the imposition of any formal organizational supervision (Freidson 1988). Despite this, it is important to note that the genre of organizational arrangements observed within this study, took place against a backdrop of health service reforms not least the introduction of Working for Patients (1989), The Patients’ Charter (1991) and the Vision for the Future (1992). To compound these developments, nursing education was still being relocated from Schools of Nursing into Higher Education establishments (UKCC 1986). These reforms resulted in students being afforded supernumerary status a concept Annandale (1998) suggests has now disappeared from wards when she states: …with student nurses no longer supernumerary on the wards, and hospital management ever more concerned to cut the expensive nursing budget, we are seeing the increased employment of a large peripheral workforce of vocationally qualified health care assistants whose work is organised by a small elite of highly qualified graduates and diplomates. From my own experience both during the study and since, the notion of supernumerary status is still not fully understood or recognized by many trained staff as the following comment by a third year student indicates: The idea that you are supernumerary is a nonsense. As far as the staff are concerned you are just another pair of hands. They just expect you to get on with the work. Because students no longer make up a formal part of the workforce, they appear to be less visible than under the apprenticeship system. Consequently, routine nursing interventions that would traditionally have fallen within the domain of student nurses have become subsumed within the health care assistants’ remit (Wakefield 1996).
© 2000 Harcourt Publishers Ltd
As the type of work that students are expected and permitted to undertake has changed, health care assistants have become increasingly valued by trained staff. Furthermore, with the introduction of National Vocational Qualifications in the late 1980s and early 1990s there has been an escalation in the health care assistants’ ability to shoulder increasingly complex work unsupervised, as the following statement by a second year student nurse demonstrates: It’s not fair you know, these care bears (a term of derision not endearment) get to do everything these days. They take out venflons and do all the dressing; all we get left with is ‘doing the teas.’ As health care assistants have become more autonomous, the scope for intra-professional dissonance has spiralled in direct relationship to the increasing credentiallation (Annandale 1998) of the health care assistant’s knowledge. This sudden growth in the health care assistant’s status has flourished secondary to qualified nurses experiencing a transformation in their caring philosophies. For this reason, hierarchically determined modus operandi have been replaced with utilitarian management philosophies.
Changes within the nursing team and its effect on students In the late 1970s, and early 1980s orthodox systems of social control were extremely status conscious organizational structures (Wakefield 1996). These structures served to distinguish each person’s role within the ward. For example, throughout the 1970s, and early 1980s, a ward’s skill mix comprised three groups of staff: 1. Untrained staff: auxiliary nurses who were classified as being the ‘fetch and carry’ element of the workforce 2. Trainee staff: students who were aspiring to be qualified nurses 3. Trained staff: those individuals’ responsible for coordinating and overseeing work tasks. In effect, the organizational arrangements outlined above were reinforced by a series of behavioural expectations, which were directly related to where a member of the nursing team
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was perceived to be within the ‘pecking order.’ In other words, if you were a junior student you were expected to be subservient to your superiors and engage in ‘rudimentary’ nursing tasks. These tasks would include washing and bathing patients as well as undertaking routine baseline observations. This latter form of social control usefully defined a student’s progress through the hierarchy towards qualified nursing status. Hence, the genres of work students were allowed to tackle, varied in accord with the level and type of knowledge they had acquired. As a result, students would be allocated work directly proportionate to their perceived cognitive ability. This informal distribution of work was not however, based on any objective measure, but a less complicated work ethic where tasks would be assigned to students based on the number of stripes they had on their uniform. In other words, third year students were perceived as being able to cope with more complicated work. In contrast, the nursing auxiliary would be assigned housekeeping work while junior student nurses would be asked to complete unambiguous nursing interventions. This stringently imposed, albeit simplistic structure also regulated whom students troubled when accessing information relating to the ward’s routines, or when trying to establish what form(s) of care they were expected to implement. Previously, very junior students tended to target senior peers, enrolled nurses, or newly qualified staff nurses for the information they required; as these were perceived as being less remote and austere than the senior staff nurses or sisters. Although students still target their peers for assistance or information regarding ward policy and procedure, the void left by the enrolled nurse had not been filled by junior staff nurses undergoing preceptorship, but health care assistants. This notion is reinforced by a first year student nurse: I keep being put with the auxiliary and she keeps telling me what to do. What am I supposed to learn from her? Surely I should be working with the staff nurses otherwise what am I training for? Another student (this time a third year) supported this view saying: I might as well have been a spare part, for all I’ve done today. The support worker’s done it all. How am I supposed to learn if no-one’s around to show me? How am I
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supposed to get management practice when they (meaning the health care assistants) get to do it all? As the above comments indicate, health care assistants are no longer seen as support staff. For this reason, it could be argued that throughout the 1990s there has been a major shift in philosophy changing the role of the health care assistant from that of the ‘fetch and carry’ element of the workforce, to one in which they have become recognized as integral members of the ward team. In contrast, student nurses have simultaneously been re-classified as largely belonging to the ward’s external order. In other words, they no longer belong to a ward or department. In effect, students have become categorized as visitors, a feature that was fervently enunciated by a health service manager when passing comment on the behaviour of students whilst on hospital property: I was in the dining room the other day and some of your students were there. The behaviour they were displaying was not what I would have expected. They need to remember they are only guests here, we could in effect ask you to vacate the premises at anytime. After all, we have to think about our performance in the league tables and the effect that might have on our contracts.
Redefining the roles between students and health care assistants Annandale (1998) describes the contemporary health service’s cultural and paradigmatic shift, as a process of internal re-stratification. This change in philosophy has resulted in ward staff re-defining the role of health care assistants and student nurses. In this latter context, ‘caring work’ has increasingly been seen as the health care assistant’s property, although this type of operation would have previously been within the student nurse’s sphere of competence. New operational tensions have therefore started to emerge within contemporary practice environments given that students’ are starting to feel as though they are treated as inferior members of the nursing team. Such ideas have largely manifest on account of students being
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allocated menial tasks as opposed to more technical operations. For example, students expect to be involved in recording vital baseline observations, or assisting with aseptic dressing procedures, forms of caring which are gradually being taken over by health care assistants. In view of this, it could be suggested that the health care assistant’s role has infiltrated what was previously acknowledged as the trained and trainee nurses’ occupational domain. Infringement of the caring territory can be seen to manifest as a ‘tacit struggle’ between health care assistants and students as they each attempt to define whom the ‘caring work’ belongs to. This striving for dominance over the work domain has been exacerbated with the introduction of the National Vocational Qualification (NVQ) Level 3 grade for health care assistants. With the advent of this new level of qualification, the distinction between nursing and caring work has become increasingly blurred, augmenting intra-professional tensions. In view of this radical reapportionment of caring work, student nurses’ consider they are not being given exposure to the type of learning opportunity they feel they need. For example, students are now demanding that their educational programme equips them with more medically oriented skills such as venepuncture and intravenous cannulation as a means of distinguishing them from health care assistants. Despite this, some health care assistants are starting to encroach on these more advanced clinical skills; especially those who have attained their Level 3 NVQ. As a result, students are becoming increasingly frustrated by an educational process that seems to value the health care assistant over the new generation of health practitioners. This de-valuing of the students’ role over that of the support worker is unwittingly reinforced by senior members of the nursing team. Especially when they seemingly allocate domestic or house-keeping duties to students as opposed to encouraging them to participate in the more technical tasks often associated with becoming a ‘proper’ nurse. Despite this modus operandi, such an approach to the division of labour is often incompatible with the students’ personal expectations, and aspirations relating to what they think, ‘nursing is all about.’ Furthermore, these latter concepts are also, at variance with the students’ personal understanding of how they
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perceive their exposure to nursing practice should unfold. Nevertheless, discrepancies between what students’ expect to occur in practice and those, which are employed in reality, are frequently tolerated because of the risks involved in making overt protestations to senior members of the ward team. For this reason, junior nurses will usually endeavour not to distort the occupational homeostasis for fear of being ‘failed’ in practice and potentially discontinued from their educational programme. However, if a student demonstrates a level of knowledge or competence above and beyond anticipated boundaries, additional unwanted troubles emerge to disrupt the ‘institutional pattern of expected activity’ (Heritage 1992). Integral to the clinical setting encountered for this study, registered nurses used comparative analytical techniques to assess the students’ capabilities. In this way, staff established what level of knowledge and/or skill it was reasonable to expect a student to demonstrate during their clinical allocation. To accomplish this informal assessment, practitioners tended to evaluate three aspects of the individual: 1. Perceived life skills: this element directly related to a student’s progress along the life span continuum and the diversity of experiences or coping strategies s/he may have amassed en route 2. Theoretical/practical competence: here the students’ level of knowledge was appraised in terms of what type of educational programme they were undertaking. For example, diploma students were seen to have less clinical experience than ‘traditionally trained nurses’ but greater experience than undergraduate students. Undergraduate students were seen by some staff to be the ‘clever nurses’ who could articulate about nursing, but could not actually do the work. Conversely, undergraduates were sometimes seen as ‘special.’ In this latter context, ward staff would direct all their resources towards the undergraduate’s educational and clinical development, to the perceived detriment of other students 3. Level of exposure to the clinical environment: here students tended to be appraised in terms of where they were in their course. In other words, how many ward allocations they had
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completed and the diversity of clinical experience they had been exposed to. When appraising a student’s capabilities, trained nurses were seen to contrast the behaviour exhibited by students’ in reality, with those of an ideal student. Although first year student nurses entering the domain for the first time would not be expected to undertake interventions demanding the same level of knowledge, or skill as those expected of a second year student. They would still be expected to demonstrate some level of clinical competence irrespective of their course of study. For example, even noviciate learners would be required to make beds, record baseline observations, wash, dress, move and handle individuals safely without having to be taught the rudiments of such interventions whilst on the ward. In just the same way as qualified staff attempted to judge a student’s competence, student nurses also exhibited an equally rigid format for determining what they felt health care assistants should be permitted to do. For example, students did not expect health care assistants to assume they possessed more knowledge than themselves. Neither did students expect health care assistants to tell them what or how to do something. A factor reinforced by a third year student one month prior becoming a registered nurse: I think that these support workers (health care assistants) take on too much. I mean, one even told me what to do the other day. I felt like saying don’t tell me how to do me job I have a damn sight more knowledge than you. As the above statement suggests whenever health care assistants’ conveyed the view that they were more knowledgeable than a student’ ‘intraprofessional’ dissonance became amplified. A feature reinforced as a consequence of the trained staff acknowledging and accepting health care assistants’ as integral members of the ward team. In this latter circumstance, it could be argued that scientific/technical knowledge was being underrated in favour of professional/practical knowledge (Eraut 1994; Hughes 1958). Hughes (1958) defined scientific knowledge as ‘the pursuit of knowledge, the value of which hinges on its effective communication to colleagues’ (Freidson 1970). While more recently Eraut (1994) has
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defined technical knowledge as being that which ‘is capable of written codification.’ In other words, a form of knowledge that is used systematically and explicitly (Eraut 1994). Because students’ receive a more diverse learning experience, it could be said that they develop scientifically orientated technical knowledge throughout their educational programmes (Eraut 1994; Hughes 1958). Conversely, it could be argued that support workers or health care assistants acquire more esoteric or ‘professional/practical knowledge’ as part of a serendipitous, repetitive process, especially as much of this knowledge is largely grounded in common sense. That is, the type of knowledge ‘which we know but cannot tell’ (Eraut 1994). Despite the implementation of rote, or competency based learning methods within the NVQ system, as opposed to the insightful learning styles favoured by nursing education, health care assistants still feel able to pass judgment about the competence of students and their ability to implement nursing interventions. This ability to make a judgment largely emanates from health care assistants’ being able to draw on a bank of information which has proved successful in the past (Garfinkel 1967). Although this bank of information or what could be termed ‘recipe knowledge’ (Schutz 1970) frequently forms the basis of all nursing actions; trained nursing staff have the ability to modify the recipe when confronted with novel circumstances. In contrast, health care assistants are often unable to adapt the principles of the recipe to new situations. This latter dilemma arises primarily because health care assistants’ lack the necessary insight and scientific knowledge on which to base their clinical decisions. As a direct result of this divergence of knowledge exhibited by students and health care assistants, new power struggles emerge within the ward, whereby each tries to exert dominance over the other.
Changes in the power relationship within the ward Changes in the power relationship between the two groups of staff outlined above creates a tension within the setting between what Parsons (1947) would call the ‘authority of office and the authority of knowledge or technical competence.’ Here the notion of authority is based upon a
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philosophy, which recognizes the existence of a shared understanding of the boundaries relating to the type of behaviours students and health care assistants are expected to exhibit and those they are not. Freidson (1970) citing Kuhn (1962) called this shared understanding a ‘common universe of discourse; a shared set of paradigms.’ When a student assumes an educational role within the caring team on account of their enhanced nursing knowledge and technical competence, they have for all practical purposes transcended the ‘hitherto’ recognized boundaries of practice. For example, health care assistants no longer expect to have their work regulated by student nurses. A feature distinct from operational arrangements espoused in the 1970s, when nursing auxiliaries would be allocated work by students. Furthermore, the type of work auxiliaries were allocated would be more in keeping with that of a housemaid rather than a fundamental member of the caring team. Within contemporary operational frameworks intra-professional tensions manifest whenever a student challenges what health care assistants’ now recognize as their official and ‘quasi-expert’ authority (Freidson 1970). In this circumstance, it could be proffered that the notion of a ‘common universe of discourse’ has been suspended (Kuhn 1962). This latter feature is particularly evident in situations where students endeavour to violate the recognized organizational discourse, by attempting to become educators and ‘quasi’ supervisors, as opposed to being merely the recipients of ‘orders.’
Conclusion Within the preceding discussion, I have attempted to outline some of the operational tensions increasingly imposed upon student nurses as the profession of nursing continues to metamorphose. As a consequence of the changes in nursing culture, students are finding it increasingly more difficult to sustain the educational process. This situation arises given that additional pressures are indirectly imposed upon learners as a result of trust hospitals’ adhering to stringent fiscal policies in a bid to keep hospital running costs to a minimum. This need to manage budgets has radically changed the caring interface resulting in the manifestation of new nursing roles. For this reason,
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contemporary nursing practice has become an occupational minefield with untrained, trained and novitiate members of staff jockeying for position within the hierarchy. Nowhere is this conflict more apparent that on ‘training wards,’ where student nurses learn to develop their clinical skills, especially when students are regarded as subordinate to the coveted NVQ Level 3 health care assistant. Yet, if the government is to achieve its target of attracting more nurses into the profession it is imperative that students are made to feel welcome on wards. If not, many potential nursing leaders will fail to complete their educational programme especially as wards become increasingly ‘hostile’ environments. In view of this, it is vital that nursing as a whole and in particular the clinical environment, takes a much closer look at itself to ensure that students gain access to the type of clinical experience they both need and expect from what should be an exciting and dynamic profession. References Annandale E 1998 The Sociology of Health and Medicine: An Introduction. Cambridge: Polity Press Baker DE 1978 Attitudes of Nurses to Care of the Elderly. Manchester University: PhD Thesis (Unpublished) Cotterill P, Letherby G 1993 Weaving Stories: Personal Auto/Biographies in Feminist Research. Sociology 27(1):67–79 Cuff E C, Sharrock W W, Francis D W 1992 Perspectives in Sociology, 3rd edn. London: Routledge Department of Health 1989 Working for Patients. London: HMSO Department of Health 1991 The Patients’ Charter, London: HMSO Department of Health and National Health Service Management Executive 1992 A Vision for the Future: The Nursing midwifery and Health Visiting Contribution to Health and Health Care London: HMSO DePoy E, Gitlin L N 1993 Introduction to Research: Multiple Strategies for Health and Human Services. London: Mosby Eraut M 1994 Developing Professional Knowledge and Competence. London: The Falmer Press Fetterman D L 1991 A Walk Through the Wilderness: Learning to Find Your Way. In: Shaffir W, Stebbins R (eds.) Experiencing Fieldwork: An Inside View of Qualitative Research. Newbury Park, California: Sage Freidson E 1970 Professional Dominance: The Structure of Medical Care. Chicago: Aldine Freidson E 1988 Profession of Medicine: A Study of Sociology Applied Knowledge. London: The Chicago University Press Garfinkel H 1967 Studies in Ethnomethodology. California: Polity Press
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Harrison B, Lyons E S 1993 A Note on Ethical Issues in the Use of Autobiography in Sociological Research. Sociology 27(1):101–109 Heritage J 1992 Garfinkel and Ethnomethodology. Cambridge: Polity Press (Reprint) Hughes E C 1958 Men and Their Work. Illinois: The Free Press Johnson M 1992 A Silent Conspiracy. International Journal of Nursing 29(2):213–223 Kelly R 1998 Nurses Talking: A Radical Policy – Ethnomethodology – For Researching Critical Care Nursing Nursing in Critical Care 3(1):41–46 Kuhn T 1962 The Structure of Scientific Revolutions Chicago: University of Chicago Press. In: Freidson E (1970) Professional Dominance: The Structure of Medical Care. Chicago: Aldine Lofland J, Lofland L 1984 Analysing Social Settings: A Guide to Qualitative Research Belmont California: Wadsworth
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Parsons T 1947 Introduction In: Weber M (ed). The Theory of Social and Economic Organisation New York: Oxford University Press Roth J 1962 Comments on ‘Secret Observations.’ Social Problems 9:283–284 Schutz A 1970 The Interdependency of the Systems of Relevance In: Zaner RM (ed). Schutz: Reflections on the Problems of Relevance. London: Yale University Press Wakefield A B 1996 The Practicalities of Organising Surgical Nursing Work. Manchester University: PhD Thesis (Unpublished) Wakefield A B 1998 Sign reading: making sense of what is going on in the ward. Journal of Clinical Nursing 7:499–504 United Kingdom Central Council for Nursing Midwifery and Health Visiting 1986 Project 2000: A New Preparation for Practice, London: UKCC.
© 2000 Harcourt Publishers Ltd
Tensions experienced by student nurses in a changed NHS culture Ann Wakefield
The ideas for this paper were generated supplementary to my undertaking a wider investigation examining what it was like to be a surgical nurse. The study followed the clinical development of four student nurses and subsequently analysed how they managed their role within the ward. From observations, a series of operational tensions or pressures extant between specific members of the ward team were identified. These tensions were seen to manifest either because students felt ‘undervalued’ or akin to ‘a spare pair of hands.’ For this reason, students directed many of their ‘negative’ comments towards health care assistants, as they felt this latter group of staff were ‘taking away’ their role. Conversely, health care assistants were observed directing their own frustrations towards student nurses, who were perceived as inefficient, uncaring or devoid of clinical skills. © 2000 Harcourt Publishers Ltd
Introduction
Ann Wakefield PhD MSc RGN RMN RNT Cert Ed, School of Nursing Midwifery and Health Visiting, The University of Manchester, Coupland Building 3, Coupland Street, Manchester, M13 9PL, UK. Tel: + 44 (0)161 275 7007; Fax: + 44 (0)161 275 7566; E-mail: ann.b.wakefield@ man.ac.uk Manuscript accepted: 23 February 2000
The wider study forming the basis for this paper examined what it was like to be a surgical nurse working within the UK’s contemporary National Health Services (Wakefield 1996). The study itself was grounded in ethnomethodological philosophies (Garfinkel 1967). In other words, I was interested in making sense of the routine practice of nursing, by examining to what extent nursing actions were features of the nurses’ everyday affairs (Cuff et al. 1992; Garfinkel 1967; Kelly 1998). During the study, it was possible to simultaneously identify a series of operational tensions extant between student nurses and other members of the nursing team, in particular health care assistants. Hence, it is intended to examine this latter element in more detail within the following discussion.
Study method Accession of data for the study was achieved via a series of field observations. These observations took place over a 4-month period within one
© 2000 Harcourt Publishers Ltd doi:10.1054/nedt.2000.0467, available online at http://www.idealibrary.com on
general surgical ward in the north of England. This data gathering technique involved me working alongside 22 permanent nursing staff and four students, a process that facilitated my ability to become actively involved in the work of the ward. As a result of engaging in what ethnomethodologists term watching and listening, it was possible to understand the setting in more detail (DePoy & Gitlin 1993). Hence, I was able to gain a more comprehensive understanding of the relationships between staff as a result of having established and sustained a many-sided relationship with the subjects being observed (Lofland & Lofland 1984). This notion of many-sided meant that I participated in the work not just as a surgical nurse, but also as an educationalist, a researcher and a colleague. To underpin these observations, a series of field notes were documented at the end of each shift (Wakefield 1996). In effect, these data gathering processes reflected Fetterman’s (1991) description of an ethnographic inquiry in which he states: The ethnographer is a human instrument. Relying on all its senses, thoughts, and feelings, the human instrument is the most
Nurse Education Today
(2000) 20, 571–578
571
Tensions experienced by student nurses
sensitive and perceptive data-gathering tool. This process of observing, participating and reviewing the fieldwork notes became the basis of the data gathering and data analysing process in its own right (DePoy & Gitlin 1993). Nevertheless, the aforementioned actions were strengthened and underpinned by data extracted from my own practice, which had been amassed over what was then a 15-year period both as a surgical nurse and nurse educationalist (Wakefield 1996). This type of data is semi-autobiographical in that it draws predominantly on the life of one individual – namely myself (Cotterill & Letherby 1993). Nevertheless, because both the field notes and autobiographical reflections were in effect documentary illustrations of the lives of many people, they too became essential features of the ethnomethodological framework used during the study. Although it could be suggested that such methods are not readily generalizable to the wider nursing population (Cotterill & Letherby 1993), it does not mean that this type of data should be disregarded. Harrison and Lyon (1992) support this view, arguing that such data allow the private and personal worlds of both the researcher and the researched to be brought into the public domain. This is particularly true for student nurses, especially as many of their concerns may not be voiced within the wider nursing arena. Although the above approach to research raises some ethical concerns, Lofland and Lofland (1984) suggest that when researchers are engaged in the covert observation of an ‘open’ setting such methods can be justified. Despite this assertion, it must be acknowledged that a ward cannot be considered a communal access zone. However, as the observations for this study were undertaken while working with students, a type of behaviour considered authentic, I felt more than able to defend the use of this method (Wakefield 1998). This latter point is particularly important, given that many of the comments relating to the issues discussed here were ‘off the cuff’ remarks, which were unlikely to be made if the students thought they were being ‘targeted’ for information. Baker (1978) would contest the above point however, stating that: If the researcher manages to avoid being unmasked during the time (s/he) is acting as a complete (concealed) participant,
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(s/he) inevitably betrays (her/his) former workmates when (s/he) reports on the research. Despite this, Roth (1962) asserts that it is impossible to gain informed consent from all those from whom data will be collected when investigating public domains such as hospitals. It must be emphasized however, that during the study I was not seeking to deceive the participants as Johnson (1992) suggests in his text A Silent Conspiracy. Instead, I felt that by employing the above methods the students were able to continue with their work unhindered, enabling them to paint a picture of the ward as they perceived it to be, without prompting or bias.
The organizational hierarchy When student nurses enter the ward at the start of their period of clinical practice, they manifest as ‘unknown quantities.’ At the outset of a student’s period of practice, qualified nurses do not always know what the student can and cannot do. For example, a ward might be required to mentor students from a variety of educational programmes each demanding that different needs and learning outcomes be met by the end of the practice period. For this reason, at the outset of the allocation nursing staff need to ascertain the extent of the student’s clinical competence. Within this framework, the notion of an organizational hierarchy is created, given that qualified nurses are able to exert dominance over the student on account of their perceivedly ‘superior’ knowledge (Freidson 1988, Wakefield 1996). This concept also reflects Freidson’s (1970, 1988) notion of professional dominance. When defining what he meant by a hierarchical division of labour within medicine Freidson (1988) stated that: All occupations in the (medical) system are given less prestige than the physician by society at large … Furthermore, there is a hierarchy of prestige and authority among paramedical workers, with nurses for example being higher than attendants and technicians. During my own study it was possible to observe similar processes to those outlined above
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being instigated as a means of reinforcing the ward’s overt divisions of labour, in which trained staff were seen as having more prestige than support workers. In other words, registered nurses were perceived to be at the apex of the hierarchy given they were able to complete their work with a high degree of ‘functional autonomy’ (Freidson 1988). The term ‘functional autonomy’ is defined here as the extent to which a worker can carry out a task without the imposition of any formal organizational supervision (Freidson 1988). Despite this, it is important to note that the genre of organizational arrangements observed within this study, took place against a backdrop of health service reforms not least the introduction of Working for Patients (1989), The Patients’ Charter (1991) and the Vision for the Future (1992). To compound these developments, nursing education was still being relocated from Schools of Nursing into Higher Education establishments (UKCC 1986). These reforms resulted in students being afforded supernumerary status a concept Annandale (1998) suggests has now disappeared from wards when she states: …with student nurses no longer supernumerary on the wards, and hospital management ever more concerned to cut the expensive nursing budget, we are seeing the increased employment of a large peripheral workforce of vocationally qualified health care assistants whose work is organised by a small elite of highly qualified graduates and diplomates. From my own experience both during the study and since, the notion of supernumerary status is still not fully understood or recognized by many trained staff as the following comment by a third year student indicates: The idea that you are supernumerary is a nonsense. As far as the staff are concerned you are just another pair of hands. They just expect you to get on with the work. Because students no longer make up a formal part of the workforce, they appear to be less visible than under the apprenticeship system. Consequently, routine nursing interventions that would traditionally have fallen within the domain of student nurses have become subsumed within the health care assistants’ remit (Wakefield 1996).
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As the type of work that students are expected and permitted to undertake has changed, health care assistants have become increasingly valued by trained staff. Furthermore, with the introduction of National Vocational Qualifications in the late 1980s and early 1990s there has been an escalation in the health care assistants’ ability to shoulder increasingly complex work unsupervised, as the following statement by a second year student nurse demonstrates: It’s not fair you know, these care bears (a term of derision not endearment) get to do everything these days. They take out venflons and do all the dressing; all we get left with is ‘doing the teas.’ As health care assistants have become more autonomous, the scope for intra-professional dissonance has spiralled in direct relationship to the increasing credentiallation (Annandale 1998) of the health care assistant’s knowledge. This sudden growth in the health care assistant’s status has flourished secondary to qualified nurses experiencing a transformation in their caring philosophies. For this reason, hierarchically determined modus operandi have been replaced with utilitarian management philosophies.
Changes within the nursing team and its effect on students In the late 1970s, and early 1980s orthodox systems of social control were extremely status conscious organizational structures (Wakefield 1996). These structures served to distinguish each person’s role within the ward. For example, throughout the 1970s, and early 1980s, a ward’s skill mix comprised three groups of staff: 1. Untrained staff: auxiliary nurses who were classified as being the ‘fetch and carry’ element of the workforce 2. Trainee staff: students who were aspiring to be qualified nurses 3. Trained staff: those individuals’ responsible for coordinating and overseeing work tasks. In effect, the organizational arrangements outlined above were reinforced by a series of behavioural expectations, which were directly related to where a member of the nursing team
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was perceived to be within the ‘pecking order.’ In other words, if you were a junior student you were expected to be subservient to your superiors and engage in ‘rudimentary’ nursing tasks. These tasks would include washing and bathing patients as well as undertaking routine baseline observations. This latter form of social control usefully defined a student’s progress through the hierarchy towards qualified nursing status. Hence, the genres of work students were allowed to tackle, varied in accord with the level and type of knowledge they had acquired. As a result, students would be allocated work directly proportionate to their perceived cognitive ability. This informal distribution of work was not however, based on any objective measure, but a less complicated work ethic where tasks would be assigned to students based on the number of stripes they had on their uniform. In other words, third year students were perceived as being able to cope with more complicated work. In contrast, the nursing auxiliary would be assigned housekeeping work while junior student nurses would be asked to complete unambiguous nursing interventions. This stringently imposed, albeit simplistic structure also regulated whom students troubled when accessing information relating to the ward’s routines, or when trying to establish what form(s) of care they were expected to implement. Previously, very junior students tended to target senior peers, enrolled nurses, or newly qualified staff nurses for the information they required; as these were perceived as being less remote and austere than the senior staff nurses or sisters. Although students still target their peers for assistance or information regarding ward policy and procedure, the void left by the enrolled nurse had not been filled by junior staff nurses undergoing preceptorship, but health care assistants. This notion is reinforced by a first year student nurse: I keep being put with the auxiliary and she keeps telling me what to do. What am I supposed to learn from her? Surely I should be working with the staff nurses otherwise what am I training for? Another student (this time a third year) supported this view saying: I might as well have been a spare part, for all I’ve done today. The support worker’s done it all. How am I supposed to learn if no-one’s around to show me? How am I
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supposed to get management practice when they (meaning the health care assistants) get to do it all? As the above comments indicate, health care assistants are no longer seen as support staff. For this reason, it could be argued that throughout the 1990s there has been a major shift in philosophy changing the role of the health care assistant from that of the ‘fetch and carry’ element of the workforce, to one in which they have become recognized as integral members of the ward team. In contrast, student nurses have simultaneously been re-classified as largely belonging to the ward’s external order. In other words, they no longer belong to a ward or department. In effect, students have become categorized as visitors, a feature that was fervently enunciated by a health service manager when passing comment on the behaviour of students whilst on hospital property: I was in the dining room the other day and some of your students were there. The behaviour they were displaying was not what I would have expected. They need to remember they are only guests here, we could in effect ask you to vacate the premises at anytime. After all, we have to think about our performance in the league tables and the effect that might have on our contracts.
Redefining the roles between students and health care assistants Annandale (1998) describes the contemporary health service’s cultural and paradigmatic shift, as a process of internal re-stratification. This change in philosophy has resulted in ward staff re-defining the role of health care assistants and student nurses. In this latter context, ‘caring work’ has increasingly been seen as the health care assistant’s property, although this type of operation would have previously been within the student nurse’s sphere of competence. New operational tensions have therefore started to emerge within contemporary practice environments given that students’ are starting to feel as though they are treated as inferior members of the nursing team. Such ideas have largely manifest on account of students being
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allocated menial tasks as opposed to more technical operations. For example, students expect to be involved in recording vital baseline observations, or assisting with aseptic dressing procedures, forms of caring which are gradually being taken over by health care assistants. In view of this, it could be suggested that the health care assistant’s role has infiltrated what was previously acknowledged as the trained and trainee nurses’ occupational domain. Infringement of the caring territory can be seen to manifest as a ‘tacit struggle’ between health care assistants and students as they each attempt to define whom the ‘caring work’ belongs to. This striving for dominance over the work domain has been exacerbated with the introduction of the National Vocational Qualification (NVQ) Level 3 grade for health care assistants. With the advent of this new level of qualification, the distinction between nursing and caring work has become increasingly blurred, augmenting intra-professional tensions. In view of this radical reapportionment of caring work, student nurses’ consider they are not being given exposure to the type of learning opportunity they feel they need. For example, students are now demanding that their educational programme equips them with more medically oriented skills such as venepuncture and intravenous cannulation as a means of distinguishing them from health care assistants. Despite this, some health care assistants are starting to encroach on these more advanced clinical skills; especially those who have attained their Level 3 NVQ. As a result, students are becoming increasingly frustrated by an educational process that seems to value the health care assistant over the new generation of health practitioners. This de-valuing of the students’ role over that of the support worker is unwittingly reinforced by senior members of the nursing team. Especially when they seemingly allocate domestic or house-keeping duties to students as opposed to encouraging them to participate in the more technical tasks often associated with becoming a ‘proper’ nurse. Despite this modus operandi, such an approach to the division of labour is often incompatible with the students’ personal expectations, and aspirations relating to what they think, ‘nursing is all about.’ Furthermore, these latter concepts are also, at variance with the students’ personal understanding of how they
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perceive their exposure to nursing practice should unfold. Nevertheless, discrepancies between what students’ expect to occur in practice and those, which are employed in reality, are frequently tolerated because of the risks involved in making overt protestations to senior members of the ward team. For this reason, junior nurses will usually endeavour not to distort the occupational homeostasis for fear of being ‘failed’ in practice and potentially discontinued from their educational programme. However, if a student demonstrates a level of knowledge or competence above and beyond anticipated boundaries, additional unwanted troubles emerge to disrupt the ‘institutional pattern of expected activity’ (Heritage 1992). Integral to the clinical setting encountered for this study, registered nurses used comparative analytical techniques to assess the students’ capabilities. In this way, staff established what level of knowledge and/or skill it was reasonable to expect a student to demonstrate during their clinical allocation. To accomplish this informal assessment, practitioners tended to evaluate three aspects of the individual: 1. Perceived life skills: this element directly related to a student’s progress along the life span continuum and the diversity of experiences or coping strategies s/he may have amassed en route 2. Theoretical/practical competence: here the students’ level of knowledge was appraised in terms of what type of educational programme they were undertaking. For example, diploma students were seen to have less clinical experience than ‘traditionally trained nurses’ but greater experience than undergraduate students. Undergraduate students were seen by some staff to be the ‘clever nurses’ who could articulate about nursing, but could not actually do the work. Conversely, undergraduates were sometimes seen as ‘special.’ In this latter context, ward staff would direct all their resources towards the undergraduate’s educational and clinical development, to the perceived detriment of other students 3. Level of exposure to the clinical environment: here students tended to be appraised in terms of where they were in their course. In other words, how many ward allocations they had
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completed and the diversity of clinical experience they had been exposed to. When appraising a student’s capabilities, trained nurses were seen to contrast the behaviour exhibited by students’ in reality, with those of an ideal student. Although first year student nurses entering the domain for the first time would not be expected to undertake interventions demanding the same level of knowledge, or skill as those expected of a second year student. They would still be expected to demonstrate some level of clinical competence irrespective of their course of study. For example, even noviciate learners would be required to make beds, record baseline observations, wash, dress, move and handle individuals safely without having to be taught the rudiments of such interventions whilst on the ward. In just the same way as qualified staff attempted to judge a student’s competence, student nurses also exhibited an equally rigid format for determining what they felt health care assistants should be permitted to do. For example, students did not expect health care assistants to assume they possessed more knowledge than themselves. Neither did students expect health care assistants to tell them what or how to do something. A factor reinforced by a third year student one month prior becoming a registered nurse: I think that these support workers (health care assistants) take on too much. I mean, one even told me what to do the other day. I felt like saying don’t tell me how to do me job I have a damn sight more knowledge than you. As the above statement suggests whenever health care assistants’ conveyed the view that they were more knowledgeable than a student’ ‘intraprofessional’ dissonance became amplified. A feature reinforced as a consequence of the trained staff acknowledging and accepting health care assistants’ as integral members of the ward team. In this latter circumstance, it could be argued that scientific/technical knowledge was being underrated in favour of professional/practical knowledge (Eraut 1994; Hughes 1958). Hughes (1958) defined scientific knowledge as ‘the pursuit of knowledge, the value of which hinges on its effective communication to colleagues’ (Freidson 1970). While more recently Eraut (1994) has
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defined technical knowledge as being that which ‘is capable of written codification.’ In other words, a form of knowledge that is used systematically and explicitly (Eraut 1994). Because students’ receive a more diverse learning experience, it could be said that they develop scientifically orientated technical knowledge throughout their educational programmes (Eraut 1994; Hughes 1958). Conversely, it could be argued that support workers or health care assistants acquire more esoteric or ‘professional/practical knowledge’ as part of a serendipitous, repetitive process, especially as much of this knowledge is largely grounded in common sense. That is, the type of knowledge ‘which we know but cannot tell’ (Eraut 1994). Despite the implementation of rote, or competency based learning methods within the NVQ system, as opposed to the insightful learning styles favoured by nursing education, health care assistants still feel able to pass judgment about the competence of students and their ability to implement nursing interventions. This ability to make a judgment largely emanates from health care assistants’ being able to draw on a bank of information which has proved successful in the past (Garfinkel 1967). Although this bank of information or what could be termed ‘recipe knowledge’ (Schutz 1970) frequently forms the basis of all nursing actions; trained nursing staff have the ability to modify the recipe when confronted with novel circumstances. In contrast, health care assistants are often unable to adapt the principles of the recipe to new situations. This latter dilemma arises primarily because health care assistants’ lack the necessary insight and scientific knowledge on which to base their clinical decisions. As a direct result of this divergence of knowledge exhibited by students and health care assistants, new power struggles emerge within the ward, whereby each tries to exert dominance over the other.
Changes in the power relationship within the ward Changes in the power relationship between the two groups of staff outlined above creates a tension within the setting between what Parsons (1947) would call the ‘authority of office and the authority of knowledge or technical competence.’ Here the notion of authority is based upon a
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philosophy, which recognizes the existence of a shared understanding of the boundaries relating to the type of behaviours students and health care assistants are expected to exhibit and those they are not. Freidson (1970) citing Kuhn (1962) called this shared understanding a ‘common universe of discourse; a shared set of paradigms.’ When a student assumes an educational role within the caring team on account of their enhanced nursing knowledge and technical competence, they have for all practical purposes transcended the ‘hitherto’ recognized boundaries of practice. For example, health care assistants no longer expect to have their work regulated by student nurses. A feature distinct from operational arrangements espoused in the 1970s, when nursing auxiliaries would be allocated work by students. Furthermore, the type of work auxiliaries were allocated would be more in keeping with that of a housemaid rather than a fundamental member of the caring team. Within contemporary operational frameworks intra-professional tensions manifest whenever a student challenges what health care assistants’ now recognize as their official and ‘quasi-expert’ authority (Freidson 1970). In this circumstance, it could be proffered that the notion of a ‘common universe of discourse’ has been suspended (Kuhn 1962). This latter feature is particularly evident in situations where students endeavour to violate the recognized organizational discourse, by attempting to become educators and ‘quasi’ supervisors, as opposed to being merely the recipients of ‘orders.’
Conclusion Within the preceding discussion, I have attempted to outline some of the operational tensions increasingly imposed upon student nurses as the profession of nursing continues to metamorphose. As a consequence of the changes in nursing culture, students are finding it increasingly more difficult to sustain the educational process. This situation arises given that additional pressures are indirectly imposed upon learners as a result of trust hospitals’ adhering to stringent fiscal policies in a bid to keep hospital running costs to a minimum. This need to manage budgets has radically changed the caring interface resulting in the manifestation of new nursing roles. For this reason,
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contemporary nursing practice has become an occupational minefield with untrained, trained and novitiate members of staff jockeying for position within the hierarchy. Nowhere is this conflict more apparent that on ‘training wards,’ where student nurses learn to develop their clinical skills, especially when students are regarded as subordinate to the coveted NVQ Level 3 health care assistant. Yet, if the government is to achieve its target of attracting more nurses into the profession it is imperative that students are made to feel welcome on wards. If not, many potential nursing leaders will fail to complete their educational programme especially as wards become increasingly ‘hostile’ environments. In view of this, it is vital that nursing as a whole and in particular the clinical environment, takes a much closer look at itself to ensure that students gain access to the type of clinical experience they both need and expect from what should be an exciting and dynamic profession. References Annandale E 1998 The Sociology of Health and Medicine: An Introduction. Cambridge: Polity Press Baker DE 1978 Attitudes of Nurses to Care of the Elderly. Manchester University: PhD Thesis (Unpublished) Cotterill P, Letherby G 1993 Weaving Stories: Personal Auto/Biographies in Feminist Research. Sociology 27(1):67–79 Cuff E C, Sharrock W W, Francis D W 1992 Perspectives in Sociology, 3rd edn. London: Routledge Department of Health 1989 Working for Patients. London: HMSO Department of Health 1991 The Patients’ Charter, London: HMSO Department of Health and National Health Service Management Executive 1992 A Vision for the Future: The Nursing midwifery and Health Visiting Contribution to Health and Health Care London: HMSO DePoy E, Gitlin L N 1993 Introduction to Research: Multiple Strategies for Health and Human Services. London: Mosby Eraut M 1994 Developing Professional Knowledge and Competence. London: The Falmer Press Fetterman D L 1991 A Walk Through the Wilderness: Learning to Find Your Way. In: Shaffir W, Stebbins R (eds.) Experiencing Fieldwork: An Inside View of Qualitative Research. Newbury Park, California: Sage Freidson E 1970 Professional Dominance: The Structure of Medical Care. Chicago: Aldine Freidson E 1988 Profession of Medicine: A Study of Sociology Applied Knowledge. London: The Chicago University Press Garfinkel H 1967 Studies in Ethnomethodology. California: Polity Press
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Harrison B, Lyons E S 1993 A Note on Ethical Issues in the Use of Autobiography in Sociological Research. Sociology 27(1):101–109 Heritage J 1992 Garfinkel and Ethnomethodology. Cambridge: Polity Press (Reprint) Hughes E C 1958 Men and Their Work. Illinois: The Free Press Johnson M 1992 A Silent Conspiracy. International Journal of Nursing 29(2):213–223 Kelly R 1998 Nurses Talking: A Radical Policy – Ethnomethodology – For Researching Critical Care Nursing Nursing in Critical Care 3(1):41–46 Kuhn T 1962 The Structure of Scientific Revolutions Chicago: University of Chicago Press. In: Freidson E (1970) Professional Dominance: The Structure of Medical Care. Chicago: Aldine Lofland J, Lofland L 1984 Analysing Social Settings: A Guide to Qualitative Research Belmont California: Wadsworth
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Parsons T 1947 Introduction In: Weber M (ed). The Theory of Social and Economic Organisation New York: Oxford University Press Roth J 1962 Comments on ‘Secret Observations.’ Social Problems 9:283–284 Schutz A 1970 The Interdependency of the Systems of Relevance In: Zaner RM (ed). Schutz: Reflections on the Problems of Relevance. London: Yale University Press Wakefield A B 1996 The Practicalities of Organising Surgical Nursing Work. Manchester University: PhD Thesis (Unpublished) Wakefield A B 1998 Sign reading: making sense of what is going on in the ward. Journal of Clinical Nursing 7:499–504 United Kingdom Central Council for Nursing Midwifery and Health Visiting 1986 Project 2000: A New Preparation for Practice, London: UKCC.
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