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FORMATION FROM A CRITICAL STANCE
WE NOTED THAT patient advocacy was often taught explicitly in the context of encountering substandard nursing practice. The powerful and sometimes dysfunctional roles of our health care institutions can have undesirable consequences for the formation and practice of nurses. At the policy level, health care institutions need to be made more hospitable and fit for good nursing and medical practice. But, if used as a teaching-learning opportunity, substandard practice can be used to inoculate students with the frontline issues in nursing, and be a source for thinking realistically about change strategies to improve practice.
Nursing students learn in complex, bureaucratic settings with economic constraints and limited resources, where the goals of the institution may clash with the goals of good professional practice. As one student explained:
I learned how hard nursing is. I saw a lot of tired nurses, too, on my floor. I think that’s good to see, too, to just be aware of, to keep myself healthy, to keep myself happy. The nurses are amazing, but they are worked, and a lot are tired. There aren’t any real breaks for a nurse. Someone can take a fifteen-minute break and walk down and get a cup of coffee, but a nurse has to stay on that floor. I can’t tell you how many cups of coffee I saw with only three sips out of them because a patient in room seven was vomiting, or something else happens, like a patient’s IV came out in room ten. It was an eye-opener.
In fact, none of the senior students we interviewed were leaving school without having had their “eyes opened” to the demands of the acute-care hospital and long-term care environments. It is clear from our interviews that improving working environments is central to any solution to the nursing shortage and to improving patient care and safety. Equally essential is addressing the substandard practice and dysfunctional work environments for students’ potential learning about change, and preparing themselves to cope with the realities of what they are likely to confront at work when they graduate. Exposure to substandard work environments can also help students identify health care delivery systems that present a better work environment.
In any health care practice, the professional must make efforts to influence the institutional context so that good practice is feasible within the bureaucratic and economic limits and organizational infrastructures of the practice setting. As one teacher pointed out, the challenge of facing patients with critical illness is compounded by the demands of the large complex bureaucratic settings in which care takes place:
I think they struggle in the clinical the most . . . just see what they see in the clinical setting. For a lot of them, it’s the first time they’ve seen people as sick as these people are, and the first time they’ve seen people dying or families in distress, and it’s really hard. And it’s the first time for some of them to see the big institution of acute care. That acute tertiary care setting is really challenging for a lot of the students, just to be in there. The communication that goes on there and the expectations and how patients are treated and how families are treated . . . just seeing this whole structure and how many problems there are with it. So, the discussions that we have in clinical conferences include what’s wrong with the system and what’s wrong with acute care and why people are so sick in the hospital. That seems to be the part that they find most challenging.… But for some of them it’s the first time they’ve been in the environment for an extended period. And then, they have to function there. So it’s not just that they’re there observing and looking and saying, “My god, look at this place. It’s really scary and dysfunctional and has a lot of problems.” They have to navigate these problems and get through that and do the best they can for their patients.
In the face of such health care inequities, students must learn how to better understand the patient’s context and how they can help patients improve their access and continuity of care. Advocating for the underserved and uninsured is a major focus of patient advocacy in the student and interviews with educators. For example, advocacy for patients on discharge is a major theme in student comments. Frequently students told stories of giving elaborate discharge teaching and instructions, only to find out that the patient was unable to afford the medications, was without insurance, or was homeless. There was no easy solution for follow-up care after extensive surgery. Commenting on such experiences, one student observed, “Our health care system isn’t perfect, and we want to try to be advocates for our patients, and I think learning about these things helps me figure out how I can exert my influence on behalf of my patients.” Another noted: “I work at a trauma center. It’s also a place that serves disadvantaged people, both jail patients, illegal immigrants, people that have newly migrated, and just having an appreciation for the system they’ve come from, their frame of mind, the system that they’re in, what benefits they’re going to get, and having some insight into their situation and maybe what’s in store for them helps me to advocate for them in their situation.”
In the best situation, the institution facilitates good practice as defined by the professionals working in the institution. The boundaries of good and poor practice are set not only by the performance, skill, and integrity of the professionals but also by the organizational context that supports or constrains best practices. The importance of patient advocacy showed up vividly when student nurses confronted substandard nursing care: patient neglect, or labeling patients as difficult, or even verbal abuse. In these areas of the breakdown or breach of good practice, the students could identify loss of patient advocacy and feel its significance for patient well-being powerfully. Teachers tried to help them:
We see practice that is less than wonderful. We see nurses who treat patients badly and nurses who don’t tell the truth to patients and things like that. And we talk a lot about, How do you deal with that when you’re a nurse? What do you do with that and how do you, as an RN on the treatment team, help LVNs [licensed vocational nurses], aides, and other RNs to look at their practice and maybe be able to make some changes? How do you do that in a way that you can be heard? How do you do that if you don’t have any institutional authority because you don’t have institutional authority the first few years you’re in practice? How do you use yourself to help to make changes in the professionalism of people?
Nurse educators must prepare students to face intransigent bureaucracies bent on cutting costs, and with little or no appreciation of the nurse’s role in making patient care safe and technologies bearable. Efforts include leadership courses, often part of BSN programs, which typically emphasize issues of practice and policy reform, especially related to patient safety (Cronenwett et al., 2007). Students are often assigned “change projects” such as introducing the latest evidence-based care for IV changes and site care, translation of patient education booklets into Spanish, identifying resources for homeless people such as mobile clinics, lobbying to ensure that mouth shields are in every room for mouth-to-mouth resuscitation, or calling an ethical consultation meeting about a common violation of patients’ right to informed consent. We noted that nurse educators understood both formal and informal change projects as addressing the nurse’s role as change agent for patient’s well-being.
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