3.1 Introduction
In this chapter we focus on students’ behaviour when undertaking clinical placements. We avoid being too prescriptive but instead profile some clinical scenarios to help you consider the potential consequences of your actions. We’ve also explored some of the more difficult situations that students may have to deal with, such as sexual harassment, horizontal violence and conflict with peers. Our aim is to fortify you so that if you encounter any of these negative and distressing situations you will have an armoury of strategies to help deal with them. Our thinking is that ‘forewarned is forearmed’.
3.2 Cultural safety
Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual beliefs. An increase in cultural diversity in Australia and New Zealand has placed greater emphasis on nurses’ ability to provide culturally competent care (see Table 3.1). This includes the ability to manage complex differences in attitudes, religion, world views and language (Kikuchi 2005; Schim et al. 2005).
Table 3.1Understanding the difference between cultural awareness, sensitivity, competence and safety | |
| Cultural awareness | Knowledge, understanding and appreciating difference and diversity. Recognising that we do not always have a shared history or a shared understanding of the present. |
| Cultural sensitivity | A process of recognising the attitudes, values, beliefs and practices within your own culture so that you can have an insight into your effect on others. |
| Cultural competence | Providing effective and appropriate, positive and empowering care to all. |
| Cultural safety | Supports a social justice approach to healthcare. Cultural safety is specific to working in a cross-cultural context with Indigenous persons. |
Ellis et al. (2010), Kikuchi (2005), ANMC and Nursing Council of New Zealand (2010), Schim et al. (2005). | |
Knowledge of other cultures is vitally important and an initial step towards understanding difference is identified as cultural awareness. To progress in your learning to become culturally sensitive, you need to recognise the attitudes, values, beliefs and practices within your own culture so that you can develop insight into your effect on others.
Cultural safety is essential to quality care. Culturally safe behaviour means making decisions based on principles such as social justice and is an outcome of education that enables safe practice as defined by the patient(ANMC and Nursing Council of New Zealand 2010). Cultural safety centres on the experiences of the patient and includes acceptance of human diversity (Kikuchi 2005; Schim et al. 2005). The Nursing Council of New Zealand defines cultural safety as ‘The effective nursing practice of a person or family from another culture, as determined by that person or family. Unsafe cultural practice comprises any action which diminishes, demeans or disempowers the cultural identity and well-being of an individual’ (2009, p. 5). In order to be culturally safe nurses must reflect on their own cultural identity and recognise the impact that their personal culture has on their professional practice.
To be effective in delivering appropriate care to Indigenous people, nurses need:
• awareness of important Indigenous issues, such as cultural differences, specific aspects of Indigenous history and its impact on Indigenous peoples in contemporary society;
• the skills to interact and communicate sensitively and effectively with Indigenous clients;
• the desire or motivation to be successful in their interactions with Indigenous peoples, in order to improve access, service delivery and client outcomes (Farrelly & Lumby 2009).
It is important to recognise that not all Australian Indigenous people are the same or that their culture is the same. There are many Indigenous cultures in Australia and a Torres Strait Islander person, for example, will not speak on behalf of Aboriginal communities from other parts of Australia. Similarly, cultural practices such as ‘sorry cutting’, a part of the grieving process, is specific to some communities in central Australia. However, not all Aboriginal people or communities do this. While you need to understand a general framework for communicating with Aboriginal people, remember that it will not apply to every Aboriginal person you meet. As a general rule you should mirror the communication behaviour of the Aboriginal person you are talking to, for example. If they look at you directly look at them; if they look away, look away also.
Coaching Tips
• Reflect on and come to know and understand your own values and culture.
• Consider the assumptions, power imbalances, attitudes and beliefs you hold that are different to those of others.
• Learn about and engage in a social justice agenda.
• Learn about, accept and seek to understand the cultural beliefs and practices of other people.
• Understand that effective communication is essential to culturally safe and competent care, and work to develop these skills (see Chapter 5).
• Be attuned to non-verbal communication (body language), silence and touch.
• Promote cultural safety and team building through open and respectful dialogue.
• Tailor your care to meet patients’ social, cultural, religious and linguistic needs as stated by the patient.
• Provide effective nursing care by working in partnership with your patients.
• Use interpreters for care requirements when language barriers are problematic (consider the sensitivity of the information that is being imparted by a third person).
• Accept and value difference and diversity in human behaviour, social structure and culture.
Consider this story: Mrs Mana was a Maori woman who had been diagnosed with lung cancer. She had been admitted to hospital for palliative care. Within a few days the cancerous lesions had grown significantly. She began to experience difficulty in breathing and underwent a procedure to remove fluid from her lung. She found the pleurocentesis (fluid tap procedure) very painful. Her doctor explained that the cancer was extremely fast-growing, and she was offered radiotherapy and chemotherapy. She was advised that these approaches would give her a little more time, but would not save her life.
Mrs Mana considered the treatment options and their associated side effects and discussed the issues with her daughters. Her main concern was the loss of hair that would result from the chemotherapy. Her cultural traditions included the belief that she must die as a whole person. She believed that without her hair she could not be considered to be a whole person. Together with her family’s blessing, she declined the treatment that may have afforded her a longer life, so that she could die according to her cultural traditions.
Learning Activity
What are your thoughts about Mrs Mana’s decisions? Consider how your practice would demonstrate cultural safety if you were the nurse caring for Mrs Mana?
3.3 Teamwork
Introducing the concept of ‘teamwork’ is difficult without resorting to platitudes and rhetoric. No doubt as a student nurse you have heard a lot about teams and the importance of teamwork. You have probably worked hard to make sure that you fit into the team. Before long you will graduate and be called upon to be a team leader. But what does teamwork really mean and what is the secret to successful teams?
Life lessons are often found in nature. The story of geese (author unknown) is a tale that will provide some enlightenment to this sometimes nebulous concept that we call teamwork.
Coaching Tips
Tale 1
By flying in a ‘V’ formation, a flock of geese achieves a greater flying range than if each bird flew alone. As each goose flaps its wings it creates ‘uplift’ for the birds that follow.
There is a lot that we can achieve on our own, and even more can be achieved with the help of colleagues. But the power of what can be achieved by a team is quantum. People who share a common direction achieve great things because they are travelling with the trust of one another. The real world of nursing is dynamic and sometimes difficult. Effective teamwork is essential to nursing because it is the support system that ‘lifts and carries’ us when we struggle. Alone the problems may seem insurmountable; together anything is achievable.
Coaching Tips
Tale 2
When a goose falls out of formation, it suddenly feels the drag and resistance of flying alone. It quickly moves back into formation to take advantage of the lifting power of the bird immediately in front.
If we had as much sense as geese we’d be willing to stay in formation with those who are headed in our direction, be willing to accept their help and advice and to give our support to others. Giving and receiving help from fellow students and nursing colleagues is what makes a team and makes the impossible seem possible.
Coaching Tips
Tale 3
When the lead goose tires, it rotates back into formation and another goose flies to the point position.
Don’t be afraid to take the lead and to encourage others. Your leadership may be specific to patient care or provide motivation and a positive direction for a study group (for eample).
Coaching Tips
Tale 4
The geese flying in formation honk to encourage those up front to keep up their speed.
Let others know that they are doing a good job or that you appreciate their feedback. Be positive and encouraging.
Coaching Tips
Tale 5
When a goose becomes sick or is wounded, two geese drop out of formation and follow it down to help protect and care for it. They stay with it until it dies or is able to fly again. Then, they launch out with another formation or catch up with the flock.
The act of caring is a wondrous human trait. Reach out to others, and show empathy and support to colleagues and peers.
3.4 Managing conflict
Conflict is inevitable and occurs in every workplace and in any relationship. Conflict is difficult and distressing, but it does provide the opportunity for stimulating discussion and for developing your interpersonal skills. Sometimes conflict arises because of a misuse of power, authoritarian tactics or condescension; sometimes it is the result of a misunderstanding or miscommunication; and at other times it is simply a personality clash.
Coaching Tips
• Ask yourself when conflict occurs if you have done anything to contribute to the situation. Try to be objective and to look at the problem from all sides.
• Keep things in perspective. If the issue is not worth losing sleep over, let it go.
• Confer with the other person in a neutral and private setting (not in the nurses’ station).
• Share your thoughts and feelings. Explain the problem from your perspective: ‘I feel …’, or ‘It seems to me …’
• Check your understanding. Listen to the other person’s perspective. Try to understand the reasons behind the conflict.
• Look for common ground and attempt a compromise. Pursue a good outcome for all involved. If the other person sees that you are willing to make some changes to achieve reconciliation, hopefully they will meet you half way.
• Try not to become defensive or use personal attacks.
• Use direct confrontation as a last resort.
• Talk to other students about similar experiences and how they handled them.
• Decide upon a course of action. If a satisfactory compromise cannot be reached, you’ll need to make a choice. If you decide to yield to another person’s decision, do so without self-pity and resentment. If you decide to stand up for your rights, be aware of relevant policies, the appropriate steps to take and who to speak to (e.g., mentors, clinical educators, lecturers or counsellors).
Other considerations
Sometimes other factors affect how you view the situation. Consider whether you or the other person involved are:
• fatigued—have you been taking care of yourself properly; could your tiredness be making you unreasonable?
• stressed—is there something happening in your personal life that is overshadowing your ability to see the situation clearly; has something happened on the ward to make the other person feel stressed (e.g., a patient death or short staffing)?
3.5 Dealing with horizontal violence
Although many nurses may not be familiar with the term horizontal violence (or workplace bullying), most have experienced it (and participated in it) at some time during their career. The concept of horizontal violence or bullying has been discussed in the nursing literature for almost two decades. It is defined as nurses covertly or overtly directing their dissatisfaction towards each other and to those less powerful than themselves (Griffin 2004). In the past it was suggested that because nurses are dominated (and, by implication, oppressed) by a patriarchal system headed by doctors, administrators and nurse managers, nurses lower down the hierarchy of power resort to aggression among themselves (Farrell 1997, p. 482). There are many obvious manifestations of horizontal violence, and others that are quite subtle. You should develop knowledge that allows you to recognize behaviours and organisational structures that may contribute to workplace bullying.
Student experience: I don’t want her (Elizabeth’s story)
You’d sit there in handover, and the manager of the ward wouldn’t allocate you to a registered nurse, so you’d say, ‘Who’s taking me today?’ And they’d sit there for ten minutes arguing and saying, ‘I don’t want her, I don’t want her’—it was really awful. They didn’t want us there and they made it really plain that they just had no interest in students. They’d say, ‘I don’t have time for students’ or ‘I’m too busy for students’ … and in front of us, too, so it wasn’t even diplomatically done.
I can sort of understand that students are hard work, they take time, they take energy, you’re busy already, but you know—we’ve got to learn somehow. And I really didn’t learn in that environment, because I felt so unwelcome there I didn’t feel comfortable. I felt like if I asked any questions I would just get told to go away.
Each day when I went home, and I thought about going back the next day I just didn’t want to. I didn’t want to be there. I really questioned whether I wanted to keep going with nursing. I certainly didn’t feel like nursing was a good thing in that particular place. And even now I wouldn’t want to work in that hospital. And that’s almost three years on.
The ten most frequent forms of horizontal violence (bullying) in nursing (adapted from Duffy (1995)and Farrell (1997)) are:
• non-verbal innuendo (raising of eyebrows, pulling faces);
• verbal affront (snide remarks, abrupt responses);
• undermining activities (turning away, not being available, exclusion);
• withholding information (about practice or patients);
• sabotage (deliberately setting up a negative situation);
• infighting (bickering with peers);
• scapegoating (attributing all that goes wrong to one individual);
• backstabbing (complaining to others about an individual instead of speaking directly to that individual);
• failure to respect privacy;
• broken confidences.
Horizontal violence is one of the most personally troubling experiences for nurses (Griffin 2004). Students undertaking a clinical placement have been identified as a group that is especially vulnerable to horizontal violence. One reason for this vulnerability is their inexperience, which makes their work subject to scrutiny and criticism. Horizontal violence can cause students significant stress, and prevent them from asking questions and feeling as if they fit in. Sometimes registered nurses excuse their behaviour by saying, ‘This is how people treated me when I was a student.’
Coaching Tips
Understanding the origins and extent of horizontal or workplace violence in nursing will help you to realise that you are not to blame and that you should not take it personally. Universities and healthcare institutions have policies and procedures for dealing with workplace issues. Staff are also designated for you to turn to for advice and support. It is important that you do not ‘suffer in silence’ if you observe or experience this type of behaviour. It is also important that you learn how to break the cycle of horizontal violence by confronting the situation rather than trying to ignore it. Confrontation is difficult but often results in the resolution of the bullying behaviour.
3.5.1 How to confront horizontal violence
Here are some examples of how to confront horizontal violence (adapted from Griffin 2004):
Action:Non-verbal innuendo (raised eyebrows, face pulling)
Response:‘I sense from your facial expression that there may be something you wish to say to me. It is fine to speak to me directly.’
Action:Verbal affront (snide remarks or abrupt response)
Response:‘I learn best from people who can give me clear and complete directions and feedback. Could I ask you to be more open with me?’
Action:Backstabbing
Response:‘I don’t feel comfortable talking behind his/her back.’ (Then walk away.)
Action:Broken confidences
Response:‘I thought that was shared in confidence.’
Appropriate behaviours for health professionals (adapted from Chaska 2000):
• respect the privacy of others;
• be willing to help when asked;
• keep confidences;
• work cooperatively despite feelings of dislike;
• don’t undermine or criticise colleagues;
• address colleagues by name, and ask for help and advice when needed;
• look colleagues in the eye when having a conversation;
• don’t be overly inquisitive about other people’s lives;
• don’t engage in conversation about a colleague with another colleague;
• stand up for colleagues in conversations when they are not present;
• don’t exclude people from conversations, or social and workplace activities;
• don’t criticise publicly.
3.5.2 Anger and aggression by patients
Occasionally workplace violence is directed at staff by patients. It is important to recognise signs in patients that may help predict violent episodes; these include:
3.6 Dealing with sexual harassment
Some authorities contend that the nursing profession has one of the highest rates of sexual harassment (Madison & Minichicello 2001). Sexual harassment is perpetuated by both staff and patients and comes in many guises. Many people tolerate it, some hardly notice it and some find it amusing in small doses and even laugh about it.
Stereotypical images of nurses have played a contributing part in sexual harassment. Media images of nurses are improving, but in the past nurses were often stereotyped as being flirtatious and sometimes sexually promiscuous. Male nurses have been stereotyped too. They are sometimes victimised for doing what for years was considered to be ‘women’s work’.
What one person interprets as sexual harassment can be considered by another as a ‘bit of harmless fun’. Harassment can run the gamut from offensive jokes or sexual comments to inappropriate touching. Sexual assaults are rare but do occur. The overwhelming majority of sexual harassment cases are between male patients and female nurses (Hamlin & Hoffman 2002). Such harassment creates tension for nurses, who must walk a fine line between meeting their professional responsibilities to patients and protecting themselves.
3.6.1 What is sexual harassment?
Sexual harassment is characterised by conduct of a sexual nature that is unwanted and unwelcome to the receiver. Conduct is considered unwelcome when it is neither invited nor solicited, and the behaviour is deemed offensive and undesirable. Sexual harassment in the workplace is an unlawful exercise of power where the harasser uses his or her authority or power to belittle, intimidate or humiliate (Hamlin & Hoffman 2002).
Harassing behaviours may include:
Coaching Tips
As a nurse you should be vigilant against sexual harassment. If someone speaks or acts inappropriately towards you this is what you can do:
• Recognise the behaviour.
• Don’t blame yourself.
• Keep a diary of what has happened.
• Tell the person involved that you are uncomfortable with this behaviour and that it offends or scares you. Some people do not realise the effect of their behaviour and are genuinely horrified when they are told that their actions are perceived to be harassing when they thought they were being friendly or amusing. Offenders need to understand that is it not what they intended that matters, but how they are perceived.
• Remove yourself from the situation if possible. If a person seems to be targeting you inappropriately, ensure that you are never alone with them.
• Give no encouragement. If someone is harassing you, don’t respond to them. Do not engage in friendly banter.
• Confide in your clinical facilitator and/or a colleague if you think someone is harassing you, even if it is only minor pestering.
• Know the policies and procedures of the educational and healthcare institutions about harassment.
• If the situation escalates, report the offender to your educator, mentor or nursing unit manager who can take appropriate action.
• If a patient speaks to you or touches you inappropriately, challenge the person immediately in a firm, clear, loud voice for other people to hear. If the harassment continues, you can ask to have another nurse stand by in the patient’s room, or refuse to care for the patient. Regardless of what you do, you should report the behaviour to a superior.
Remember that sexual harassment is against the law. All educational and healthcare institutions have policies to protect against sexual harassment. Do not tolerate it (or perpetuate it) in any form.
3.7 Taking care of yourself
Nursing students are a healing presence to others. It is essential that you care for yourself to enable you to continue to care for others and to practise safe nursing (Stark et al. 2005). The Australian Nursing and Midwifery Council (ANMC) National Competency Standards stipulate that you should ‘consider individual health and well-being in relation to being fit for practice’ (ANMC 2006, p. 3). Caring for yourself requires that you proactively adopt healthy lifestyle choices. Practising a healthy lifestyle will enable you to cope with the demands of nursing. You are responsible for your own health, and a holistic assessment of your health and well-being will help you to identify your needs and any problems that require a change in lifestyle or a review of your ability to practise nursing. Equip yourself with knowledge about health and wellness. Select appropriate strategies and commit to making healthy choices. Caring for yourself needs to be a priority before you can care for others.
One area that students often struggle with is maintaining adequate rest and sleep patterns. Fatigue causes many of the same symptoms as those caused by a raised blood alcohol (e.g., being 17 hours sleep-deprived equates with having a 0.05 blood alcohol concentration) (Australian Transport Safety Bureau 2010). This makes you unsafe to practise. If alcohol consumption and fatigue are both present then your symptoms are intensified. The only real cure for tiredness and sleep deprivation is, of course, sleep, with adults needing approximately six to eight hours of quality sleep each 24 hours (Cliff & Horberry 2010).
Coaching Tips
• Eat well, get enough rest and sleep, exercise regularly and be kind to yourself. Take a few minutes each day just to reflect and dream in solitude. Take this time to renew yourself physically, mentally, emotionally and spiritually. Private time is not a luxury—it is a necessity.
• Keep your body hydrated, especially during busy shift periods.
• Assess your own health and set up a personal plan that addresses your needs and problems. Seek professional health advice as necessary—many gyms will assist you with health advice.
• Ensure that you are familiar with the immunisation requirements for practice. Most educational institutions require you to provide evidence of having complied with these requirements before you are authorised to begin your clinical placements.
• Manual handling injuries are one of the most common reasons for nurses’ absenteeism. It is vitally important that you learn safe patient-moving techniques and practise these at all times.
• You’ll learn a lot about infection control during your studies. Remember that infection control protects both your patients and you!
• Learn to say no to people who put excessive demands upon you. Learn to say yes to activities you really enjoy.
• Develop time-management skills to help you juggle study, friends, family and work. Prioritise and don’t leave things to the last minute (the extra stress is just not worth it).
• Implement strategies to lessen the effects of lifestyle and work stressors. Try to eliminate as many of these stressors as possible.
• Practising one or more mind–body therapies is an effective self-care strategy to help restore peace and balance. Learn how to engage in mindfulness meditation, a technique for promoting relaxation and improving focus and clarity of mind. It has been reported to reduce stress, burnout anxiety and depression, and increase concentration, and memory (Wahbeh et al. 2008).
• Set up support networks with colleagues for clinical placements. These can include childcare support networks, travel groups and study groups.
• Seek professional and academic advice about the impact that a disability may have on your practice or your learning. Most universities have disability officers who can provide support and advice, whether your disability is new, temporary or permanent.
3.8 Advocacy
Patient advocacy is an essential responsibility for all health professionals—it is no less an obligation for students. To be an advocate means that you empower and uphold the rights and interests of others. Patient advocacy is defined as ‘defending the rights of the vulnerable patient, or acting on behalf of those unable to assert their rights’ (Thompson et al. 2000, p. 20). The demonstration of competent practice requires nurses to ‘advocate for individuals/groups when rights are overlooked and/or compromised’ (ANMC 2006). Ways to advocate for and to empower others include:
3.8.1 Student advocacy
As well as acting as advocate for others, you may require an advocate yourself at times during your nursing career. In some circumstances your clinical educator may be able to advocate on your behalf, or your lecturer may be the person who can best represent your interests. Do not hesitate to request this type of support. You should also be aware that there are professional advocates available, and a search of websites (e.g., student unions the types of professional groups, and nurses’ associations) will identify services available.
Coaching Tips
• Identify the essential human rights that a nurse must respect in order to be a patient advocate.
• Identify your responsibilities as a patient advocate.
• Carefully gather relevant information related to the situation and patient before addressing an issue. Try to stand back and analyse all issues objectively.
• Empower patients to self-advocate rather than taking over (that is, allow patients to ask their own questions of members of the interdisciplinary healthcare team). Perhaps set the scene so that patients are able to ask their questions or suggest they write their questions down before a consultation.
• Provide patients with information that enables them to make informed decisions.
• Identify the most appropriate person to speak on your behalf should you need an advocate.
3.9 Best practice
Something to think about
Often when we visit students on a clinical placement we ask them questions like ‘What are you doing?’, ‘Why are you doing it?’, ‘Why are you doing it that way?’ and ‘Is there a better way?’ We’re always thrilled if they can provide evidence-based justification for their practice. Too often nursing care is based upon little more than tradition or authority. Let us explain.
As a nursing student you will learn how to practise nursing, and some (hopefully most) of what you learn will be research-based. Millenson (1997)estimates, however, that 85 per cent of healthcare practice has not been validated scientifically. Nursing practice relies on a collage of information sources that vary in dependability and validity, and some sources of evidence and knowledge are more reliable than others (Dawes et al. 2005).
3.9.1 Sources of evidence and knowledge
Tradition
In the nursing profession certain beliefs are accepted as facts and certain practices are accepted as effective, based purely on custom and tradition (the way we’ve always done it). These traditions and customs may be so entrenched that their use and usefulness is not questioned or rigorously evaluated. It is worrying when ‘unit culture’ (the way it is done here) determines the way practice is undertaken, rather than basing clinical judgements on the best available evidence.
Authority
Another common source of knowledge is an authority figure, a person with specialised expertise and/or in a position of authority. Reliance on the advice of authority figures, such as nursing managers, educators or academics, is understandable. However, like tradition, these authorities as a source of information have limitations. Authorities are not infallible (especially if their knowledge is based mainly on personal experience), yet their knowledge often goes unchallenged.
Clinical experience
Clinical experience is a familiar and important source of knowledge. The ability to recognise regularities and irregularities, to generalise and to make predictions based on observations is a hallmark of good nursing practice. Nevertheless, personal experience has limitations also. Individual experiences and perspectives are sometimes narrow and biased.
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