Essay title - Problems encountered by nursing students - A study into violence
Introduction
A very famous quote by Martin Luther King Junior states that “our lives begin to end the day we become silent about things that matter”. The quote perfectly reflects the importance of the topic of discussion in this paper. The paper is aimed to discuss one of the major problems encountered by nurses and nursing students i.e. violence. In contemporary nursing profession the extent of violence is rapidly increasing, so the need arises to equip nurses and nursing students to combat with the problem. Nurses as a vulnerable population have always been subjected to occurrences of different types of violence which adversely affect their physical, psychological, emotional, and social health and ultimately cause them distress as professional. In this paper, I will discuss the general and contextual significance of the problem, examine few mechanisms to address the issue, and propose a working framework to combat the problem.
Reasons for Selecting the Topic
The paper focuses on the population of nursing students therefore; later discussion will examine the significance of the issue in nursing students. In this section of the paper, I will present background of the problem through real case scenarios that I observed during my professional experiences. A first year nursing student was excited to be on a clinical floor of one of the tertiary care hospitals in the city. She was a hardworking student, and was extremely committed towards nursing profession. She was assigned in an adult health Medical/Surgical Unit for her summer clinical rotation. In the rotation, students used to work independent without direct supervision of the faculty however, would be supervised by nursing staff of the unit. The nursing student was naive in the profession so needed lot of professional support from the nursing staff. In other words, she was dependent on them for her personal and professional growth. This dependency subjected her to different forms of violence. In result, she was persistently harassed by a nursing assistant who would pass suggestive comments and ask sexual favors from her. Consequently, she experienced extreme emotional and psychological trauma. The nursing student, who primarily was committed to the profession, experienced extreme sense of disconnection from the profession. On another occasion, the Bio-Ethics Working Group of Aga Khan University (AKU) arranged a ground round on the topic of violence among employees. In that grand round different true cases were anonymously presented. In one case, it was mentioned that a scrub nurse assisting the surgeon, had to leave the operation theater momentarily. The surgeon asked the student nurse to hand him a specific instrument. Mistakenly, the student nurse handed him the wrong one for which he got angry and threw the instrument in her face. Similarly, I have observed several times that nurses and student nurses are verbally abused, bullied, and harassed by patients, family members, physicians, and co-workers. The issue is very critical to nursing profession, however, nursing students’ lack necessary knowledge and skills to deal issues of violence. The problem is further perpetuated by extremely insufficient and ineffective systemic processes that do not safeguard nursing students from incidents of violence. Moreover, there is lot of international literature available regarding issues of violence in nursing, but there is significant lack of contextual-based empirical evidences that could have provided extent and possible solutions of the problem in Pakistan. Due to above mentioned reasons; I have selected the topic of violence for this paper, and therefore will propose a framework to address this sensitive issue.
Significance of the Problem
Violence in contemporary society is rapidly becoming prevalent. The general impact of violence affects working conditions of almost every industry. Thus, health care industry can be anticipated to encounter mild to severe forms of violence. The working conditions of healthcare industry have always been stressful for the health care professionals because of various reasons. First of all, it deals with humans (patients) and their uncertain health conditions. Moreover, health care professionals are required to be able to fulfill the health care needs of their patients. Those patients, on other hands, pay for the care received therefore; they expect quality services from their providers. In this exchange, if patient’s expectations are unsatisfactorily met or remain unmet, it may end up into situation of hostility or abuse from patient and their family. Furthermore, in certain situations, violence from patients is a result of their unstable psychological conditions like psychiatric patients. However, in some instances violence is provoked by health care professionals and is directed to patients, family or colleagues. Thus, one can anticipate the high prevalence of violence and its reasons in any given health care industry.
Nurses are called “the back-bone” of health care institutions because they come in closest contacts of the customers (patients). Hence, satisfaction level of the patients is directly linked with care provided by the nurses. Nurses therefore, bear enormous burden of fulfilling the expectations of patients, family, physicians, supervisors, and organization. This tremendous amount of responsibility makes them vulnerable to incidents of violence. Henry and Ginn (2006) cited a report from Department of Labor which estimated rate of violence as 38 cases per 10,000 workers for nursing and personal care facilities. In contrast, private industry reported to have three cases per 10,000 workers, which is relatively very low. This evidence clearly indicates that nurses are the most vulnerable population among health care team members to encounter violence. Jackson, Clare and Mannix (2002) mentioned different forms of violence for example, bullying, horizontal violence, oppression, sexual harassment, racism, and physical assault. Woelfle and McCaffery (2007) and Lee and Saeed (2001) also regarded oppression and horizontal violence as the most common form of violence directed to coworkers. Furthermore, Dowell (1992), Beech and Leather (2003), Randle (2003) and Ferns and Meerabeau (2008) have studied violence to nursing students and proposed different strategies to help them recognize, prevent and manage the violent situations. Nursing students are more vulnerable to be subjected to different types of violence due to their limited knowledge and skills. Nursing students who were mentioned in earlier two scenarios were victimized due to their positions of being naive learner. Moreover, nursing students feel threatened to report cases of violence due to fear of being blamed upon or judged by their faculty or superiors. The study by Bronner, Peretz and Ehrenfeld (2003) also revealed that nursing students remain passive in reporting incidences of sexual harassment. Workplace violence has significant negative impacts on physical, psychological, emotional, and social health of nurses and nursing students. Various literatures have noted that workplace violence has direct adverse impact on nurses’ job performance which includes low productivity, absenteeism, low morale, turnover, demotivation, and anxiety. Hence, it is evident that violence at workplace adversely affects health care professional’s personal and professional growth and therefore, it is essential to prevent and control the incidences of violence at workplace. Further in the paper, contextual significance of the problem will be discussed and practical framework will be proposed to overcome the problem.
Contextual Significance of the Problem
Violence in Pakistan is very common as evidenced by concurrent, unstable social and political situations. Therefore, one can inevitably anticipate increased numbers of incidences of violence in health care settings. Nurses and other health care professionals in Pakistan encounter different types of violence almost everyday. However, nursing education in Pakistan fails to provide adequate knowledge and skills to nursing students to combat violence at workplace. The emergent topic of workplace violence is not a part of Pakistan Nursing Council’s (PNC) curriculum. Even at Aga Khan University School of Nursing (AKU-SON), this topic is not exclusively included in any of the courses of the curriculum. However, the nursing students of year one who are inducted in the program for the first time at AKU-SON receive two hours of session in their Orientation Program titled “Gender Biasness and Harassment”. I have taken these sessions for those new students and experienced that students would have lots of queries, concerns, fear, and anxiety around the topic. Those concerns could not be resolved in two hours session; instead it demands continuous support, reinforcement and guidance. Moreover, the concept of Advisor-Advisee and Student Counselor at AKU-SON are very beneficial for nursing students to be guided and supported for their academic activities. However, nursing students seldom or never reported cases of violence to their advisors or counselor. It will be inappropriate to assume that students must not have encountered any form of violence therefore, they never reported. Lee and Seed (2001) studied oppression and horizontal violence in Pakistani nurses and found out that it is very common due to low status of women in the society. Moreover, they found out that nursing faculty and nursing students both lack knowledge and skills to address this type of violence.
Furthermore, there is extreme lack of effective policy and procedures to deal with the cases of violence in academia and workplace. At national level, laws are documented but implementation of those laws has always been questionable. Institutions on other hand don’t possess explicit policies and procedures to address workplace violence. At AKU, few academic policies are in placed to regulate discipline on the campus. According to Academic Council of AKU (2007, November 22) clause number 5.2 claims that acts “… of intimidation, insult, abusive language, assault, molestation or harassment of students, staff, faculty, patients or other clients, within or outside the University” (p. 4) will be considered offensive. Its penalty could range from counseling to expulsion form the University according to severity of the offense committed. However, Academic Council has no documented policy that safeguards students from violence.
The Personnel Department of AKU provides two policies in which cases of violence can be handled. One could infer that policy of “Employee Discipline” regards some acts as major offenses, for example, “Disorderly Behaviour”, “Abusiveness”, and “Unprofessional Conduct” (The Aga Khan University Personnel Policies & Procedures Manual, 2000, February 01). Though these clauses explicitly are not regarded as acts of violence, one could infer that employee’s behavior can be regulated or evaluated through these clauses of the policy. Another policy which could safe guard employee, faculty, or student from violence is called “Employee Grievances” (The Aga Khan University Personnel Policies & Procedures Manual, 2000, February 01). The mentioned policies have not explicitly spelled the word violence and to-date no policy has explicitly documented steps against violence at workplace. Although the university has some policies to regulate discipline, it doesn’t provide explicit policy and procedure that safe guard against workplace violence. Henry and Ginn (2006) suggested that all organizations should possess “comprehensive violence prevention policy and procedural manual”. Moreover, they should be having an established “violence prevention programs” for all employees. This section of the paper has revealed the contextual significance of the problem, further on I will provide a framework based on some leadership and management theories.
Leadership and Management Theories Linked to the Problem
Redmann (2006) and Bolman and Deal (2003) have cited Maslow’s Hierarchy of basic human needs as a basic tool to determine the need of human resource of the organization. They asserted that though Maslow’s five basic needs: physiological, safety, belongingness and love, esteem, and self-actualization lack empirical value, they are still widely used concept in management. In relation to the topic of this paper, nursing students’ basic needs according to Malsow’s would be similar. Moreover, students would seek safety more often whenever encounter situations where violence could be a potential result. Redmann (2006) further added Alderfer’s Existence, Relatedness, and Growth (ERG) Theory, which was a derivative of Maslow’s work. According to this theory, “existence” comprises physiological and safety needs, “relatedness” consists of belongingness, and “growth” includes self-esteem and actualization. Initially, when nursing students enter into the profession, they strive to maintain their existence. Nursing faculty and administration need to provide full support to ensure existence of nursing students into the program. Due to support and guidance of faculty and administration, students feel relatedness to the organization and profession. Once relatedness is achieved, they can pursue growth in their career. The ERG Theory can be applied in devising strategy to overcome experiences of violence in nursing students. For example, a victim of violence who experiences lack of support and security from faculty and administration will doubt his/her existence in the program, will feel disconnected, and therefore will not be able to pursue personal and professional growth. Thus, the foundation theory of Maslow and modified version proposed by Alderfer, provide a guideline for a leader to strategize actions that has capacity to fulfill nursing students’ personal and professional needs.
Another theory which can be applied in the prevention of violence is Herzberg’s Motivation-Hygiene Theory. According to this theory two factors affect behavior of an individual. First is hygiene factors which include “…security, status, money, working conditions, interpersonal relations, supervision, and policies and administration” (Redmann, 2006. p. 487). Instead of growth producing, these hygiene factors are only claimed to be sustainers of the productivity. If these factors are made available to an individual, it would prevent loss of productivity and dissatisfaction. Second factor is motivators which include “…growth and development, advancement, increased responsibility for work, challenging work, recognition, and achievement” (Redmann, 2006. p. 487). Hence, one can infer that the hygiene factors are the pre-requisite for the motivator factors. Intact hygiene factors will keep an individual satisfied with job and later, the satisfied individual can pursue growth via motivator factor. This theory can be applied in the scenario of violence prevention among nursing students. For example, faculty and administration ensure provision of all hygiene factors to the nursing students; in result they will stay satisfied with their organization and profession, and finally they will seek motivators to advance in their profession. Conversely, the students who are deprived of hygiene factors mainly security, stable working conditions, and effective interpersonal skills, will be unsatisfied and may not advance in the profession.
These theories provide very basic and practical guidelines to establish a working framework for administration to devise appropriate strategies for preventing and controlling violence in nursing students.
Proposed Framework to Prevent and Control Violence
After critical review and synthesis of the empirical evidences, I have proposed a practical framework to prevent and control violence experienced by nursing students. The model is termed as the Three E’s Model: Estimate the prevalence of violence, Educate and train, and Establish and provide support system.
Ferns and Meerabeau (2008), Celik and Celik (2007), Goldberg (2007), Woelfle and McCaffery (2007), Beech and Leather (2003), Bronner, Peretz and Ehrenfeld (2003), Jackson, Clare and Mannix (2002) Lee and Saeed (2001), and Dowell (1992) have studied and cited various studies that reflect significant prevalence of different types of violence in nurses or nursing students. The prevalence of violence in those studies appears to be more than 50% in majority of the cases, which is an alarming situation. On the basis of the severity of the problem, administration develops plan of actions. Therefore, to prevent and control the incidences of violence, one needs to know the severity of the problem in their context. This proposition has led me to suggest the first step of the three E’s Model, which is “Estimate the prevalence of the problem”.
Ferns and Meerabeau (2008), Goldberg (2007), Woelfle and McCaffrey (2007), Beech and Leather (2003), Jackson, Clare and Mannix (2002) Lee and Saeed (2001), and Dowell (1992), and Bullough (1990) have proposed different strategies to train and educate nurses and nursing students to combat violence effectively. These empirical evidences have provided broad knowledge about carefully planned interventions for violence prevention. This led to the development of the second step of the Model i.e. Educate and Train. Literature asserts that any education, training, and awareness program devised to address violence prevention should be based on the need of the population. After prevalence estimation, administration could plan an effective and relevant violence prevention program.
Ferns and Meerabeau (2008), Celik and Celik (2007), Goldberg (2007), Woelfle and McCaffery (2007), Beech and Leather (2003), Bronner, Peretz and Ehrenfeld (2003), Jackson, Clare and Mannix (2002) Lee and Saeed (2001), and Dowell (1992) have stressed upon the need of effective organizational and legal support for nurses and nursing students. The training and education sessions will be of less value, if effective support systems have not been established in the organization. The victims of violence remain passive and refrain from reporting the incidence due to lack of support system within the organization. Moreover, the fear of breach of privacy and confidentiality is an issue which tend them to remain silent. Finally, lack of safety and security hinder them to raise voice against violence. Therefore, the most important step in the Model is to Establish and provide support systems. The three E’s are interconnected and affect each other (See Figure 1).
Recommendations
In this section few practical recommendations are provided under each step of the Three E’s Model. These proposed strategies can be applied at AKU, AKU-SON or in any health care setting of Pakistan. The strategies are formulated after careful review and critical synthesis of the literature.
Estimate the prevalence. An administration can take following actions to attain the
first step of the model, few suggestions are as follows:
- Assess the severity of the problems at different points in time for example at beginning of first year, after each summer clinical, before the graduation and so on.
- Identify appropriate questionnaires to assess prevalence of different types of violence for example, Goldberg (2007) have cited Fitzgerald’s Sexual harassment Experience Questionnaire (SEQ) which is widely used in examining prevalence of sexual harassment at workplace.
- Collaborate with Bio-Ethics Working Group at AKU who has been working as whistle blower in the organization. Identify different working groups that can demonstrate willingness to attain measure the extent of the problem for example Working Group of Women (WGW).
Educate and train. After measuring the extent of the problem, administration needs to develop an effective and relevant training program. The program should aim to address all possible needs of the individual. The training session needs to be taken by faculty or trainers, who have relevant experience in dealing violence related issues. As such sessions are recommended to be conducted in a workshop setting, it is also important to have a student or employee counselor available for those who encounter emotional trauma due to recall memory.
- Each student should receive a comprehensive training before entering into formal nursing education.
- The training, continuing, or awareness sessions should focus on increasing and building knowledge, awareness, attitudes, and skills.
- The trainings should be provided to each student in a workshop setting and should be part of the curriculum.
- The education sessions should be arranged for the faculty in order to enhance their knowledge and skills to facilitate students in preventing, combating, and controlling violence.
Establish and provide support systems. Finally, processes should be implanted in the organization to address the issues of violence effectively.
- Strengthen the Advisory-Advisee, Student Counselor, Employee Assistance Program concepts.
- Introduce explicit and stringent policies for preventing, reporting, and controlling violence.
- Liaison with other departments for example, Nursing Services, Safety and Security, and Human Resource Development to identify the factors of violence and strategize preventing measures.
- Demonstrate Zero-Tolerance towards incidences of violence.
Conclusion
Nursing is regarded as caring profession. A nurse is appreciated for her holistic approach in providing care to people in need. While nurses take care of the patients in the health care setting, it is administration’s responsibility to take care of the care providers. Woelfle and McCaffrey (2007) concluded that “In addition to caring about patients, nurses will have to care about the profession of nursing and find new and innovative ways in their practice to support nursing. As a result nurses may begin to support each other” (p. 131). Nurses need to work collectively against violence because it is intolerable.
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