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Be brave and report poor practice

Raising concerns can be difficult, especially for nursing students who fear the consequences of making an official complaint. But patient safety is paramount, and all healthcare staff have a duty to report poor care, writes Erin Dean.
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Raising concerns can be difficult, especially for nursing students who fear the consequences of making an official complaint. But patient safety is paramount, and all healthcare staff have a duty to report poor care, writes Erin Dean

Finding an older, immobile patient stranded in his bed soaked with urine after his carers failed to turn up was a distressing experience for nursing student Carey Jehu.

But what made it even worse was the attitude of the district nurse she was on placement with, who failed to act with any urgency and joked about the mans situation when they got back in the car.

Ms Jehu, who is just starting her third year in adult nursing at Kings College London, says: The patient had obviously been like that for a long time.

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Raising concerns can be difficult, especially for nursing students who fear the consequences of making an official complaint. But patient safety is paramount, and all healthcare staff have a duty to report poor care, writes Erin Dean

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All healthcare staff have a duty to report poor care. Picture: iStock

Finding an older, immobile patient stranded in his bed soaked with urine after his carers failed to turn up was a distressing experience for nursing student Carey Jehu.

But what made it even worse was the attitude of the district nurse she was on placement with, who failed to act with any urgency and joked about the man’s situation when they got back in the car.

Ms Jehu, who is just starting her third year in adult nursing at King’s College London, says: ‘The patient had obviously been like that for a long time. The nurse looked through the notes and said the carers hadn’t been for 12 hours. That was pretty shocking but the nurse didn’t seem bothered, saying he would call someone when he got back to the office.’

Difficult position

Ms Jehu felt the care provided to this patient fell well below the standard he should have received. She discussed it with a nurse at the general practice where her community placement was based, who supported and encouraged her to discuss it with her personal tutor. They subsequently raised it as an official concern with the trust.

Ms Jehu provided a written statement, although she does not know what the outcome has been for the nurse involved.

Ms Jehu found herself in a difficult position many students may recognise – seeing examples of poor care on clinical placement.

‘I obviously want to be part of the team and don’t like telling on people, but patient safety is more important’

Carey Jehu

The Nursing and Midwifery Council (NMC) says students who are concerned that a registered nurse or midwife is not fit to practise, or who have witnessed poor practice or a risk to public protection, have a duty under the Code to make their concerns known.

Students are also covered by the duty of candour, a professional responsibility to be honest and open with patients when things go wrong. But raising concerns can be difficult for students, who may not know how to do it or fear the consequences of making an official complaint.

Ms Jehu says raising a concern is not easy. ‘It is difficult and awkward. I obviously want to be part of the team and don’t like telling on people, but patient safety is more important.’

Focus on support

A greater focus has been placed on supporting nurses and students to blow the whistle since the report by Sir Robert Francis on failings at Mid Staffordshire NHS Foundation Trust.

The Freedom to Speak Up review, published in 2015, found that staff who raised concerns in the NHS were often bullied, ignored and intimidated, with almost one third saying they felt unsafe afterwards.

The report highlighted the damaging impact that raising a concern can have on a student’s career. Students have failed placements after raising concerns, lost their university place and suffered detrimental treatment from co-workers or managers while they remained on that placement.

An international review of nursing student encounters with poor care, published in the journal Nurse Education in Practice earlier this year, found that students do not always report it because they fear the consequences. When they do report it they have a strong commitment to professional guidance and a clear moral position.

‘It is a professional requirement of the NMC that we respond to concerns about the quality of care’

Robin Ion

Robin Ion, one of the authors of the review and senior lecturer and head of the division of mental health nursing and counselling at the University of Abertay in Dundee, says it is ‘absolutely imperative’ that concerns are raised.

‘It is a professional requirement of the NMC that we respond to concerns about the quality of care,’ he says. ‘There is also a moral responsibility to do something about it, and in some cases a legal requirement if it constitutes a criminal offence.

‘But Francis observed that some of the testimony of people who have raised concerns is harrowing,’ he adds.

Mr Ion says policies about raising concerns will generally direct students to their mentor or the academic for the area at their university. But if the problem is their mentor, or a failing team with a poor manager, raising concerns and getting a good response is that much harder.

Need for guidance

He says there is a need for clear, national guidance that addresses the difficulties students face. ‘Guidance is needed that identifies accountable officers in practice and education, and timelines for feedback to students,’ he says.

In her role as Freedom to Speak Up guardian at Staffordshire and Stoke-on-Trent Partnership NHS Trust, nurse practitioner Helene Donnelly works closely with students and universities to make it easier for them to raise concerns.

She holds drop-in sessions and appointments to gather feedback from students about their placements, with students raising issues about poor care during these confidential meetings.

‘Students get to see a lot of good practice but also things that aren’t quite as good as they should be, and they pick up things other people stop seeing’

Helene Donnelly

Every trust should have a Freedom to Speak Up guardian who students can approach if they are not happy with how a concern has been dealt with, or if a mentor has dismissed the issue, she says.

‘Students are an amazing resource. They come in with fresh eyes, and they see and hear everything,’ says Ms Donnelly, who is also the trust’s ambassador for cultural change.

‘Students get to see a lot of good practice but also things that aren’t quite as good as they should be, and they pick up things other people stop seeing,’ she adds. ‘Awareness of raising concerns is growing, but there is still a lot more to do.’

Student shunned after raising concerns

Mental health nursing student Naomi Bentley says the first time she raised a concern during a first-year placement with a crisis team was horrific.

The Birmingham City University student was sent out with a band 3 healthcare assistant to the home of a patient who they found was at risk of committing suicide.

When Ms Bentley, now in her third year, handed over the patient she felt her concerns were not listened to by the senior nurse, who went off to lunch.

Desperately concerned about the safety of the woman, and about to finish her shift, she escalated a concern through the official trust reporting system, and contacted the practice placement manager.

On her next shift, she says she was interrogated about her report, shunned by many staff members, and felt the complaint was not properly investigated. ‘It was a traumatic, isolating and persecuting experience,’ she says. ‘It greatly knocked my confidence to work autonomously.’

Breaking point

But when she raised a concern in a placement at the end of her second year there was a much more positive outcome.

Two members of staff were speaking to her rudely and dismissively in front of colleagues and patients. When she contacted the practice placement managers and requested a move to a different placement, the manager of the unit responded very differently.

At mediation, he said her experience was unacceptable, and that she would not have to work with the staff members again. He encouraged her to stay, and at the end of the placement she received the highest marks possible.

Ms Bentley says the experience of raising concerns needs to be easier. ‘I did the right thing and would do it again, but it was still difficult. Students have to reach their emotional breaking point to escalate their concerns, and it shouldn’t be like that.’


Erin Dean is a freelance health journalist 

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