This is the second in our series on moral courage. The first article discussed what moral courage means and why it is important to nursing in general. This article will focus more specifically on why moral courage is important to nursing students and some of the barriers they face when trying to use it during clinical placements.
Why do nursing students need moral courage?
Nursing students are more likely than any other health profession to be exposed to poor practice, including the physical or emotional abuse of patients, students or staff, breaches of patient safety, privacy and dignity, provision of substandard or outdated care, clinical errors, and working outside of one’s scope of practice. They are more likely than any other health professional student to witness or be asked to participate in situations that jeopardise patient safety. Yet, the majority of nursing students remain silent in these situations, lacking the moral courage to intervene, despite feeling a moral obligation to act.
Why is this happening? Why don’t nursing students demonstrate moral courage and speak up in these situations? To answer this, I started looking into the existing research on the topic. With the help of my honours supervisors, Tracy Levett-Jones and Peter Sinclair, we conducted a formal literature review, and this is what we found.
Five major themes were identified: just a student, don’t rock the boat, fear of consequences, mentor-student relationship, and patient advocate identity. Other minor themes were lack of confidence and previous response.
‘Just a student’
Nursing students saw themselves as being subordinate, invisible and having no credibility. One student described themselves as being ‘only’ or ‘just a student’. The students viewed their supervising RNs as sitting much higher on the healthcare hierarchy and, as such, believed they had no right to question anything they did. Even when they were certain patient safety was at risk, students felt forced to remain “silent in the world of just being a student”. This was reinforced when those on the ward, including NUMs, RNs and allied health professionals, also dismissed them as ‘just the student’ and left them feeling insignificant.
‘Don’t rock the boat’
Students have a strong desire to fit in when on clinical placement. This can create a reluctance to question poor practice and instead go along with whatever their RNs ask in order to ‘fit in’. Students see themselves as guests on the RNs ‘turf’ and are not willing to jeopardise their acceptance by ‘rocking the boat’. This desire prevents them from taking even easy steps to reduce patient distress and can see them cast aside their own morals to avoid standing out. The ‘eat our young’ reputation of nursing only serves to increase this behaviour.
Being accepted during placement is seen as paramount and described as being key if the student wanted to have a ‘good’ placement. Questioning an RN’s practice was not worth the risk of alienation. It was described as feeling that “if you don’t get on with somebody then your whole placement is going to be ruined”.
‘Fear of the consequences’.
Mentor/Supervising RNs have a huge amount of power over students, especially on unfacilitated placements. Students have a genuine fear of reprisals by the RN if they dare to question their practice. This can include being failed by the RN, deliberately being excluded from learning opportunities and outright bullying. Students know RNs can make their placements extremely hard as retribution and so choose to remain silent, even if patient safety is at risk.
Hopefully, it is evident by this point how crucial mentors are to nursing students. Students know the quality of their placement can depend on the quality of their mentor. A mentor who addresses the power imbalance and treats their student as an equal, creates an environment where students feel comfortable asking questions and challenging practices. Conversely, those who have a poor relationship with their mentor and more likely to go along with unethical or even dangerous practices.
Our students are watching us, even when we don’t realise it. They observe our behaviour and integrate it into their own practice. If they see us NOT questioning or reporting poor practice, they are more likely to do the same. If, on the other hand, we show them how to advocate for our patients and respectful ways to challenge practices, they will follow suit.
Patient advocate identity
There were a few students who did have the moral courage to speak out when faced with poor practice. These students all strongly identified as a patient advocate. Acting as a patient advocate gave them the courage to act, risking potential reprisals and/or repercussions and instead prioritising patient safety and dignity.
Lack of confidence
Students’ confidence in their clinical knowledge plays a large role in their decision to question an RN. Students don’t want to look foolish and so remain silent unless they were 100% sure they were right and even then, they would doubt themselves. Given students may have no healthcare experience before commencing their nursing degree, and they view their RN as the ‘expert’, there to guide and teach them, poor practice can make them question their own knowledge over someone who may have many years of clinical experience. However, as students’ confidence in their abilities increases, so does their willingness to question substandard practice.
As with most human behaviour, response to previous actions will determine future action. Students who receive a good response – positive reinforcement, support, gratitude – are more likely to challenge poor practice again. Those who did suffer negative consequences, such as being ignored, belittled or having to face the wrath of an insulted RN, said they would stay quiet if faced with a similar situation again.
Where do we go from here?
Well, while most students do not have the moral courage to speak up when witnessing poor practice, we do know there are students who do. The next step was to find out what gave these students the moral courage to act when the majority of their peers don’t. The results of that research will be discussed in a blog post coming shortly.
There is something you can do, starting the very next time you have students on your ward. We do need to figure out how we can develop moral courage in our nursing students, but we also need to work on how we act as mentors to these students. How we act is the key – did you pick up on that? If we welcome students onto the ward, if we treat them as equals, if we encourage them to speak up and ask questions, we can help them flex their moral courage muscles. We need to demonstrate the behaviour we want them to replicate when they are working along side us as colleagues. Don’t silence them. Don’t dismiss them. Don’t belittle them. Show them how to advocate respectfully. Teach them to seek clarification not confrontation. Educate them on the power of their voice and maybe remind yourself of their power of your own.
(If you would like to read the full literature review with references, the published journal article can be found at – Collegian article )