Failure to report as a breach of moral and professional expectation

Cases of poor care have been documented across the world. Contrary to professional requirements, evidence indicates that these sometimes go unaddressed. For patients the outcomes of this inaction are invariably negative. Previous work has either focused on why poor care occurs and what might be done to prevent it, or on the reasons why those who are witness to it find it difficult to raise their concerns. Here we build on this work but specifically foreground the responsibilities of registrants and students who witness poor care. Acknowledging the challenges associated with raising concerns, we make the case that failure to address poor care is a breach of moral expectation, professional requirement and sometimes, legal frameworks. We argue that reporting will be more likely to take place if those who wish to enter the profession have a realistic view of the challenges they may encounter. When nurses are provided with robust and applied education on ethics, when ‘real-world’ cases and exemplars are used in practice and when steps are taken to develop and encourage individual moral courage, we may begin to see positive change. Ultimately however, significant change is only likely to take place where practice cultures invite and welcome feedback, promote critical reflection, and where strong, clear leadership support is shown by those in positions of influence across organisations

Rocking the boat - nursing students' stories of moral courage: A qualitative descriptive study

© 2016 Elsevier Ltd. Aim: This paper profiles a qualitative study that examined how undergraduate nursing students demonstrate moral courage when confronted with clinical situations that negatively impact the quality of patient care and/or patient experience and the factors that encouraged or inhibited their willingness to speak up when they identified poor practice. Background: Clinical placements are an essential component of nursing programmes. However, placements are a reported source of stress for students, with many witnessing, or feeling compelled to participate in, poor practice. In these instances, nursing students require the moral courage to raise concerns in order to protect patient safety and dignity. Methods: This was a qualitative descriptive study. Nine nursing students and one nursing graduate from one semi-metropolitan university in Australia were interviewed and the data were thematically analysed. Findings: Four key themes emerged: (1) patient advocate identity, which had two sub-themes of knowing one's own moral code and previous life experiences; (2) consequences to the patient and to the participant; (3) the impact of key individuals; and (4) picking your battles. Conclusion: This study demonstrates the importance of undergraduate nursing students identifying as patient advocates, the multitude of consequences students face when questioning the practice of a registered nurse, and the influence supervising nurses and clinical facilitators have on a student's decisions to intervene to protect patient safety. Further research is required to examine the factors, both intrinsic and extrinsic, that influence nursing students' moral courage and their decisions to intervene when poor practice is witnessed

Moral courage in undergraduate nursing students: A literature review

© 2015 Australian College of Nursing Ltd.Aim: The aim of this review was to explore factors which facilitate or inhibit undergraduate nursing students' willingness to demonstrate moral courage when confronted by poor patient care. Methods: Included papers were those that met the criteria of being qualitative research that explored undergraduate nursing students' depictions of situations where moral courage was or was not demonstrated during clinical placements, with a particular focus on situations that impacted or had the potential to impact the quality of patient care.Papers were reviewed using the Critical Appraisal Skills Programme Qualitative Research Checklist. The 15 papers included in the review were then thematically analysed. Findings: The literature reports, despite feeling a moral obligation to act, most nursing students lack the moral courage to intervene or speak up when faced with poor practice. While students may subsequently report the behaviour, at the time of the event, they often remain passive spectators and sometimes even active participants. The major themes identified in the literature were: just a student, don't rock the boat, fear of consequences, mentor-student relationship, and patient advocate identity. The literature also identified that nursing students suffer ongoing moral distress when they do not have the courage to confront poor practice. Conclusion: There is a need for further research to explore positive examples of how nursing students demonstrate moral courage when undertaking clinical placements. These narratives have the potential to influence future students' attitudes, values and behaviours by providing stimulus materials for teaching

Inclusive learning, diversity and nurse education

Students embarking on undergraduate nursing programmes face many challenges. They must adapt to raised academic expectations, learn a bewildering new range of skills, values and behaviours, and begin to negotiate complex and emotionally demanding practice environments and relationships. In addition to practicalities such as moving away from support networks, constrained finances and perhaps being in a work environment for the first time, nursing students must incorporate changes into their personal identities and form a professional sense of self. How well students are supported to respond to these expectations via their own networks and through engagement and connection with their new profession and programme can shape their potential for achievement. The nursing profession advocates for non-discriminatory inclusive care for all, as well as advocating for a wider diversity of care professionals. This means actively promoting inclusion in programme recruitment and development strategies. However, these aims are hindered by student attrition which is a significant issue throughout higher education in Britain including nurse education. Data published by the Higher Education Statistics Agency (HESA) in 2016/17 indicates that students facing multiple disadvantage are more likely to leave university in their first year than their peers. As well as being a clear example of social injustice, unequal completion rates reduce the projected workforce and disrupt supply and planning. Discounting gender disparities, nursing has a strong record for recruiting and training a broad range of students, but completion rates emerge as lower than for other subjects. An influencing factor here may be that as the professional demands of nursing have intensified, so has the academic rigour required to deliver corresponding competency requirements. Nurse educators need to be creative and flexible to enable students to engage with complex learning which ranges from higher order thinking skills, and philosophical and ethical understandings, to intricate physical tasks. This creates challenges for inclusive curriculum design as well as needing to effectively facilitate it, it must be accessible to a diverse body of nursing students who may have strengths in terms of life experience but who present across the range of academic competence and confidence. Inclusive learning and teaching is advocated as best practice in providing a response to these issues. However, inclusivity is a contested concept, with varied uptake and it sits within a higher education context of financial restrictions, larger class sizes and a push for more online provision. What is clear though is that academic outcomes across student groups are unacceptably varied with significant attainment gaps for those with multiple disadvantages. A key question for nurse educators is how best to develop an evidence base for the pedagogical approaches that are most likely to enable the completion of successful student nurse journeys for all, regardless of their starting point