More than ‘noticing and speaking up’? How free to ‘speak up’ are nursing students? Council of Deans of Health workshop: Students Speaking Up 6th May 2015 To cite: A suggested citation format is below. If required, a DOI number will also be available shortly via my ResearchGate profile for this paper/pilot report, see URL at the foot of this page. Thank you. Cox, N. (2015) More than noticing and speaking up: how free to ‘speak up’ are nursing students? Theoretical contexts and data analysis from a pilot project. Paper presented to Council of Deans workshop: Students Speaking Up, London, 6 May 2015.
Dr Nigel Cox Senior Lecturer | Faculty of Health, Psychology & Social Care (Nursing) Manchester Metropolitan University | Birley Campus | M15 6GX
[email protected] | researchgate.net/profile/Nigel_Cox2 Funding of this pilot project was provided by an MMU internal staff research accelerator award
Workshop outline 1: Theory and early research findings • Revisiting the current context and the challenges • Innovating theory and contextualising to nursing • Findings (student voices) from my pilot study 2: Workshop practical / take-home ideas • Round-table discussion • Developing ideas for brief group feedback • Individual task, one idea to ‘take home’ to HEI 2
Familiar contexts • • • •
Mid Staffs NHS Foundation Trust Public Inquiry1 Quality of care and treatment (Keogh review)2 Freedom to speak up (Francis/independent review)3 Raising concerns NMC guidelines/+ revised Code5 “[junior doctors and student nurses] are capable of providing valuable insights, but too many are not being valued or listened to ... In some trusts we visited, junior doctors are not included in mortality and morbidity meetings because they were considered ‘not adult enough to be involved in the conversations’”4
1 Francis
2013; 2 Keogh 2013; 3 Francis/Freedom to speak up 2015; 4 Keogh 2013:12 5 Nursing and Midwifery Council 2013 (revised 2015) 3
Problematisations • Care staff may be reluctant to report mistreatment 1 • Trainees have a role to play in reporting concerns 2 • ‘Corrective’ response from nursing: – Special roles and procedures specific to ‘raising concerns’ – Training regimes, e.g. Values Based Recruitment 3 – Rules of conduct, e.g. 6Cs 4
• Emphasis has been upon: – Normalizing (regulating, controlling) students and others – Restoring behaviour, ‘something in the nurse to be fixed’ 5 1 CQC
2013; 2 Francis 2013/15; 3 HEE 2014; 4 Cummings 2012; 5 Wright 2014:33
Question: Are underpinning student injustices underexplored? 4
New ways to understand the problem • Thinking of students as speaking/listening agents - How is students’ capacity (their agency) to ‘speak up’ cultivated or damaged in educational contexts?
• How do students work to avoid epistemic injustice? - Which can be considered in two ways:
Testimonial injustices: “occurs when prejudice on the part of the hearer leads to the speaker receiving less credibility than he or she deserves” 1 Hermeneutic injustices: “lack[ing] the resources, usually conceptual resources, that are required for formulating important problems or for addressing them” 2 1 Fricker
2003:154, 2007, 2010; 2 Hookway 2010:152; informed also by work from Foucault, Rose, Austin, Turner, etc. with regard to anthropological theory/speech acts 5
Aims of my research in-progress 1. To explore epistemic injustices in relation to nursing students wishing to ‘raise concerns’ about healthcare 2. Support and advance methodological, theoretical and analytical practice in this regard, specifically: Can we research epistemic injustice?
Can we develop theory-practice in this regard?
What are the ethical issues in doing so?
How might we think differently in education?
(1) My research is not focused on exposing specific care concerns; (2) Regular ‘raising concern’ support and research protocol in situ; (3) Ethical approval granted (2014)
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Research design • Methods – In-depth individual semi-structured interview (N=4) – Semi-structured group interviews (n=2, total N=7)
• Participant criteria – Inclusion (inc. student, placement experience, 18+) – Exclusion (exc. currently involved/reported a concern)
• Analytical method – – – – 1
Verbatim transcription (data loaded into Nvivo software) Close/cross-reading and interpretation of texts Push/pull cycle between theory and fieldwork data This stage, deductive (borrowing/extending theory) 1
derived from Haugh 2012 7
Selection, recruitment and ethics • Independent selection/recruitment (avoid coercion) – Call for volunteers via electronic learning platform – Independent selection/recruitment by administrator – Screen out prior/ongoing involvement in raising concerns
• Maintain concordance with professional standards – Research should not be planned venue for raising concerns – So, raising concern protocol embedded into recruitment – Clear parameters for confidentiality/anonymity
• Final selections – Majority female participants (reflecting nursing discipline) – Year 2 (N=5) and Year 3 (N=6) nursing undergraduates – No Year 1 students met criteria (practice experience) 8
Typical interview questions RP:
Can the concept of epistemic injustice be usefully applied to the problem of raising concerns in practice?
CRQ2 How does the concept of testimonial injustice relate to healthcare students? TQ2.1 Do healthcare students consider themselves to be credible agents? IQ2.1.1 Who can say confidently that something is a ‘concern’?
IQ2.1.2 IQ2.1.3 1 RP-CRQ-TQ-IQ
Who do you think should raise concerns about care? Do you feel confident/competent to do so yourself? (probe: why/not?)
typology/model, see Wengraf 2001
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The power of being an insider/outsider? Analytical aim 1: to explore how student nurse ‘positionalities’ are understood and practised
• Students as ‘part-outsiders’ encouraged to become ‘eyes and ears in a hospital setting’ to spot concerns/raise standards • Paradoxically - calls to socialise potential recruits into healthcare practice prior to formal training – ‘insiders’? • This begs questions about insider/outsider roles and the value and power of students’ liminal (‘in-between’) status
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Being an insider vs. outsider “It is very difficult …coming in like as fresh eyes and thinking ‘oh, I don't really want to be doing it [delivering care] that way; I want to be doing it [how I’ve] been taught [in University]’”
“And towards even students … you go onto a ward for the first time and they're all discussing how inadequate we are … You feel like you have to sort of say nothing so they won't turn on you when you're going on a new placement.” 11
Emerging findings 1: summary • Student nurses identified cliques relating to the group dynamic/local culture and were strongly aware of their insider/outsider positions • Students were strongly aware of this, describing it in positive terms (‘fresh eyes’); i.e. taking up and rehearsing official/ authoritative discourses • However, there is evidence of epistemic violence being done (‘they're all discussing how inadequate we are … how they were taught was the better way’) 12
Evidence for/of testimonial injustices
Analytical aim 2: to explore how nursing students experience being overtly disbelieved or dismissed
• Keogh report: are student nurses seen by others as ‘not adult enough’ to contribute knowledge? • Are student nurses subject to testimonial injustices? If so, what form does this take?
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Testimonial injustices “sometimes when you go on placement the staff [will say to you] ‘Oh you just go around wearing rose-tinted glasses. You’re just not used to being in the NHS yet. You just haven’t experienced real life’. And sometimes you question yourself and you think, well I am thinking that this is a concern because I don’t know any better?”
“I think I’m quite assertive in the way that I am and I also know some of the barriers that would come with raising those concerns … so as a student, apart from the fact that potentially I could fail placement and not have my documentation finished … [I would raise concerns]” 14
Emerging findings 2: summary • Student utterances/knowledge subjected to epistemic violence, i.e. deemed ‘rose tinted’, not ‘real life’ • Provoking of uncertainty/self-doubt amongst students, serving to limit the students confidence to ‘speak out’ • A perceived risk of assessment failure should they be seen as a troublemaker by placement staff • Despite own positive self-appraisal as ‘assertive’ – this is moderated – surviving/need to ‘pass’ their assessment 15
Foreclosing injustice: silencing oneself
Analytical aim 3: to explore how student nurses may act to silence themselves in anticipation/to foreclose epistemic violence being done to them
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Being silenced/silencing oneself “I’ve been in a similar situation where I’ve brought something in front of the Matron, Sister and staff nurses all together in a room … when I said what I wanted to say [and] backed it up with relevant evidence … and literally [everyone in the] room just went [mockingly] ‘Oooh’ and … did nothing about it” Obviously if there was patient care that was compromised then you would have to… you would do something about it … but … I think it’d be really rude to go and try and challenge something … without backing yourself up a little bit more. I think you have to scope it out … [instead of going] in like a bull in a china shop” 17
Emerging findings 3: summary • Strong insight into what is perceived to be the potentially deleterious personal consequences of raising concerns, and demonstrated the application of a range of strategies • Others practised a cautious, albeit purposeful naivety doing so allows them to recognise the localised nature of ‘knowledge’ in nursing practice - as outsiders • Some interactions require the nursing students to make purposeful and well thought-through decisions about how to communicate with mentors • Students make efforts to initiate, repair or sustain a productive relationship with their assessors; the personal stake they have in this relationship makes this necessary 18
Getting through: surviving/resisting
Analytical aim 4: to explore how student nurses ‘survive’ and safely resist encounters that are epistemically damaging to them – what do they say?
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Exercising power/resistance “So maybe a patient is being moved by their armpits instead of doing adequate moving and handling, in those circumstances I will say things like, ‘Ooh, can we do it my way?’ … I’ll pretend to be sort of airy-fairy stupid student nurse type thing and I’ll be like ‘Ooh I’m not sure we should be doing that because university, you know, they don’t let us do it this way. Can we do it this other way, you know, just because I’m silly’
…so I will put myself in a kind of… I wouldn’t say beneath them but in a kind of, oh I know less than you but can you just indulge me on this occasion? And then at least I know that … we’ve done something non-harmful” 20
Emerging findings 4: resisting • Some respondents identified ways in which they attempted to preserve patient well-being despite testimonial injustices being done to them • However, to do so, some respondents reported the need to ‘act out’ naivety, performing verbal concordance • Such interactions illustrate how epistemically-injurious circumstances can be (partially) avoided through skilful (albeit insincere) interactions by nursing students • However, this interaction also illustrates how the authority to speak cannot be presumed by those who do ‘speak out’, despite their sound moral intentions
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Departure points/ongoing analysis • The liminality (in-between status) of the student nurse appears fundamental to ‘raising concerns’ and these data support the notion that this should not be eroded • Might earlier socialisation of students merely quicken their enculturation into oppressive cultures of care? These data suggest how this can easily happen. • The political rhetoric (e.g. 6Cs) is helpful to students and such ‘compassion discourses’ do confer upon students an an authoritative ‘language’ they can use • However, student nurses’ navigation of the ‘politics of care communication’ are nuanced, in some cases very sophisticated, yet are mostly (rightly?) untutored 22
Workshop activity • Small groups/tables • Flipchart activity for brief group feedback Group task: what do we currently do in nurse education to: • Create testimonial/hermeneutic injustices? (challenging!) • Help overcome testimonial or hermeneutic injustices? Individual task (take home message or pledge) • Is there one thing I can do… to change my practice or lead the practice of others in learning/curriculum delivery? THANK YOU Dr Nigel Cox | Senior Lecturer | Faculty of Health, Psychology & Social Care (Nursing) Manchester Metropolitan University | Birley Campus | M15 6GX
[email protected] | researchgate.net/profile/Nigel_Cox2
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Selected references CQC/ICM (2013), Fear of raising concerns about care: A research report for the Care Quality Commission. At: http://www.cqc.org.uk/content/one-nine-reluctant-speak-out-about-poor-care Accessed: 01 June 2014 Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry: executive summary (Vol. 947). The Stationery Office. Francis, R. (2015). Freedom to Speak Up: an independent review into creating an open and honest reporting culture in the NHS. London: Freedom to Speak Up. Fricker, M., 2003. Epistemic injustice and a role for virtue in the politics of knowing. Metaphilosophy 34, 154–173. Fricker, M., 2010. Can there be institutional virtues?, in: Oxford Studies in Epistemology. pp. 235–252. HEE (2014) Health Education England Strategic Framework 2014-2029. Leeds, Health Education England. Hookway, C., 2010. Some Varieties of Epistemic Injustice: Reflections on Fricker. Episteme 7, 151–163. doi:10.3366/epi.2010.0005 Keogh, B., 2013. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. At: http://www.nhs.uk/nhsengland/bruce-keogh-review/documents/outcomes/keogh-review-final-report.pdf Accessed: 01 June 2014 Wright, S., 2014. Many factors influence our ability to be compassionate. Nursing Standard 28, 33–33. doi:10.7748/ns2014.01.28.22.33.s46 See also www.nmc.org.uk/standards/code for Code effective from 31 March 2015, and associated documents.
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