Nursing is an applied science requiring hands-on learning experiences where students demonstrate understanding of the knowledge gained in the classroom. It is presupposed that during this time, nursing students will learn how to organize and provide physical care, evaluate the effectiveness of that care, and develop professional relationships with both patients and colleagues (American Association of Colleges of Nursing [AACN], 1998). For the students, it is a time of both observation and participation during which they learn how to be a “real” nurse (Chesser-Smyth, 2005; Fitzpatrick, While, & Roberts, 1996; Ware, 2008).
The ideal clinical experience fosters development of psychomotor, cognitive, and affective skills while affording early socialization into the profession. It is expected that during these experiences, nursing students will encounter illustrative exemplars of the professional values of competence, altruism, autonomy, justice, respect, and ethical integrity (AACN, 1998). For many students, it is the seminal highlight of their education, a materialization of their vision of what it means to be a professional nurse. Eagerly anticipated and inherently stressful, the experience is approached with both excitement and anxiety. This study explores one aspect of stress—empathic anger—experienced by junior nursing students during their initial clinical rotations.
Thomas (2003, p. 18) identified common sources of student anger in response to classroom activities:
- Faculty unfairness, rigidity, or discrimination.
- Unreasonable faculty expectations.
- Hypercritical feedback.
- Unexpected changes.
- Unresolved personal problems outside the educational setting.
Published research about the initial clinical experiences of students is scarce; however, most authors agree that the primary stressors arise from issues related to performance and socialization. Clinical assignments are more stressful than any other experience during their beginning year (Jones & Johnston, 1997) because students are uncertain about what is expected of them by both their instructors and the RN on the assigned units (Andersson, 1993; Burnard, Binti, Rahim, Hayes, & Edwards, 2007; Cooke, 1996).
Although students “desperately want(ed) to perform well” (Jackson & Mannix, 2001, p. 273), they nervously anticipate being asked to do things that exceed their knowledge and ability (Cooke, 1996). Already embarrassed by unfamiliar sights, they worry about causing their patients more pain and suffering through their inexperience (Admi, 1997). This self-recognized lack of knowledge and experience in caring for patients, even at the most basic hygiene level, further increases their pervasive anxiety (Admi, 1997; Beck, 1993; Cooke, 1996; Jones & Johnston, 1997; Sheu, Lin, & Hwang, 2002).
Idealistic, although not necessarily naive, many students view nursing as more than just a job; it is a “way of being” to which they and others are “called” (Andersson, 1993). The students view a good relationship with the RNs at the clinical site as the most crucial influence on their professional growth and development (Cameron, Schaffer, & Park, 2001; Chesser-Smyth, 2005; Fitzpatrick et al., 1996; Jackson & Mannix, 2001; Levett-Jones, Lathlean, Higgins, & McMillan, 2009; Randle, 2001). From the students’ perspective, the ideal clinical experience involves unit RNs who are warm, receptive, friendly, and understanding; they include the students in planning and implementing patient care, explain why things are done, and allow students to safely ask questions (Andersson, 1993; Chesser-Smyth, 2005; Halarie, 2006; Jackson & Mannix, 2001; Lemonidou, Papathanassoglou, Giannakopoulou, Patiraki, & Papadatou, 2004).
Unfortunately, accounts from student research participants reveal a harsher reality. At best, the students report being treated as if they were invisible; at worst, they come away feeling humiliated and abused (Burnard et al., 2007; Curtis, Bowen, & Reid, 2007; Jackson & Mannix, 2001). Students want to fit in and feel like a competent member of the team (Chesser-Smyth, 2005; Cooke, 1996; Jackson & Mannix, 2001); they do not want to be “excluded, ignored, and even disliked” (Jackson & Mannix, 2001, p. 275). Many nursing students see the RNs as powerful and feel extremely vulnerable in clinical situations. Feeling unable to deal with the situation, the only action they take is to remove themselves mentally and physically (Curtis et al., 2007; Halarie, 2006). When asked about the situation, students say they feel like crying because they are unlikable; the only action they can think of is “to hide away” and “not... think anymore” (Curtis et al., 2007, p. 815). Begley and Glacken (2004) reported that during the initial stage of professional socialization, students made themselves less visible through passive silence for the express purpose of successfully completing the course.
Even more distressing to students than being treated badly themselves is watching patients receive uncaring treatment. The students expect care to be “humane, sensitive and individualized”; anything less is an ethical breach on the part of the RN (Lemonidou et al., 2004). What Randle (2001) calls “the intentional oppression of patients” leaves students feeling disappointed, shocked, and hurt, if not ashamed, defeated, and despairing. Clinical experiences are “eye openers” that can trigger feelings of disgust, dismay, and anger to the point that students may question the rightness of their career choice (Beck, 1993; Halarie, 2006).
Setting and Sample
The study was conducted in the college of nursing of a large university in the southeastern United States during a 4-year period from 2003 through 2007. Following institutional review board approval, all second-semester junior nursing students (approximately 90 per year) enrolled in a leadership course were invited to participate. Of 248 narratives submitted during the 4 years, 27 were eliminated because they did not relate to the nursing student role. Of the remaining 221 narratives, the 36 involving the students’ participation in direct patient care were analyzed for this project. No demographic data were collected for the study; however, the majority of the students in the course were Caucasian women in their early 20s.
In preparation for a class regarding anger and emotional management, junior nursing students wrote a one-page to two-page narrative about a time when they had experienced anger in either the didactic or clinical setting. No other guidelines or restrictions were provided. Papers were submitted to the course coordinator electronically. Students willing to participate in the research indicated that their paper could be saved for future study. Narratives submitted by students not wishing to participate were discarded at the conclusion of the course. After the instructor had removed all identifiers (student, faculty, patient, and institutional names), the participating students’ compositions were transmitted to the primary researcher. The researchers were not known to the students and had no role in grading decisions. In addition, participation in the study was not considered in grade computation.
All 221 narratives were analyzed by the primary researcher who first separated the narratives according to setting: didactic versus clinical. Incidents of vertical violence perpetrated on students by RNs and others, a different provocation for anger in the clinical setting, are described elsewhere (Thomas & Burk, 2009). The clinical narratives that directly involved RNs partnered with the students for the provision of direct patient care were analyzed for this project. All of the patient care settings in the narratives were inpatient medical-surgical units in metropolitan hospitals. Because the management class for which the narrative was written was held early in the second semester, the incidents had occurred during the first 4 months of student clinical experiences.
Conventional qualitative content analysis, as defined by Hsieh and Shannon (2005), was conducted to identify patterns in the narratives. Stories were scrutinized, and data were coded for response to the research questions:
- What caused students to become angry?
- How and to whom was the anger expressed?
- What was the outcome of the incident?
As principal investigator for this project, the author read the narratives line-by-line multiple times to understand the students’ experiences. Credibility of the interpretation then was enhanced by analysis of the narratives within an interdisciplinary interpretative research group; narrative texts were read aloud in the group, meaning was discussed, and commonalities were identified.
Students in this sample were often specific about time, place, and people involved in the situation. Several students started their narrative with a variation of “the first time I experienced anger in a clinical experience was my first day of my very first clinical.” From the words used, it was obvious that the memories were vivid and the resultant emotions intense.
Causes of Anger
Anger is a reflection of the students’ beliefs and values; expression of the anger is a judgment statement. With few exceptions, the students’ anger was on behalf of their patients and related to their perception of substandard care. Students expressed the belief that proper care consists of (at a minimum) keeping the patient clean. Meeting this standard of care was considered a moral obligation; failure to meet the standard was an ethical violation of the nurse’s responsibilities. Students were quite graphic in their descriptions of the patients’ condition: “dirty fingernails, dirt between the fingers, and eyes with layers of thick gunk keeping them closed” and “he had a central line that was so corroded with dirt, dried blood, feces, and no telling what else that that was what caused the horrific odor” are striking examples. One student related:
I entered my patient’s room for the first time...to find that the patient was lying in bed covered in his own feces.... I honestly do not know if he tried to call a nurse or not, but I do know that he had been lying in that bed for a while because it was very difficult to clean him up because the feces were dried and stuck to him, and his skin was very red.
Although a few narratives clearly attempted to provide a balanced report, most were emotional. One student described her patient as:
...gasping for air...halfway hanging off the bed like he was at any moment going to fall onto the floor. I went over to him and he looked up at me with the most pitiful eyes you have ever seen.
The anger was more intense if students thought the neglect was intentional. In their eyes, this constituted an even more serious ethical violation as the students believed that every patient deserved the best possible care regardless of medical history, lifestyle, or habits. Students reported a complete disconnect between their clinical experience and what they had been taught in the classroom about accepting and caring for patients despite the nurse’s personal preferences or discomfort. They were dismayed to find RNs justifying the provision of only minimal care after patients had been “labeled as a creep.” One student reported being furious when the patient’s assigned RN “also said that he had such a tremendous body odor that she purposely avoided going into his room.”
Another student related:
I reported his pain level to his primary nurse who responded, “It’s not his pain that needs to be treated, it’s his mood and his mouth. I’ll get to him eventually.” Again, I was furious!
Students reported that nurses erroneously and unfairly judged the patients’ needs and motivations as illustrated in the following narrative:
Throughout the day, the nurse also would delay the patient’s scheduled narcotic pain medications, at times as long as 2 hours. Upon confronting the nurse, she said the patient was a drug abuser because he asked for the medication by name at the exact time they were first available. The patient was clearly in pain, and further assessment on the nurse’s part would have revealed to her that this particular patient had previous hospital experience and knew how busy nurses can get and did not want her to forget about the medications.
When the students were instructed to ignore the neglect, they thought they were being made at least partly responsible for the maltreatment. One student reported that she became angrier after speaking about one such incident to her instructor. The student stated, “My instructor told me to just proceed as the nurse had indicated. She said, ‘Let’s not cause problems.’”
Disrespectful treatment beyond physical care also provoked anger. Verbal disparagement of the patients frequently took the form of gossip during shift reports or in the break room. More direct abuse of patients occurred at the bedside. One student commented:
The patient’s nurse and one of the CNAs entered the room and began conversing about the patient in a negative manner right beside his bed. They were saying things such as, “Yeah, he’ll be gone by tomorrow. I guarantee it. I don’t even know why they have you students bothering with him.” The disrespectful way that these individuals were talking and treating this poor man infuriated me to the point where I had to excuse myself.
When the patient died 3 days later, the student noted:
The nurses had been right when they said he didn’t have much longer, but I am still upset at how uncomfortable and miserable his last few days must have been.
For the most part, students became angry on behalf of the patients who they viewed as extremely vulnerable, describing them as suffering, helpless, in extreme distress, isolated and alone, abandoned, and powerless. One student commented:
My patient did not have the capacity to do those things for herself, and it angered me that no one took the time to do it for her.
On rare occasions, the anger students felt was on their own behalf when the provocative incident resulted in more unpleasant work for them (such as cleaning up feces or providing total care without assistance). Anger was exacerbated by nurses who did not take action regarding the students’ concerns and failed to explain why. Overall, the students portrayed the RNs involved as unprofessional, negligent, incompetent, and uncaring. At the end of the narrative, one student shared her opinion of the RN: “I thought she was about as responsible as a third-grade girl.” In describing their own reactions, students said they were angry, furious, infuriated, outraged, and frustrated as well as astounded, nervous, puzzled, troubled, sad, and overall, “emotionally distraught.” As one student wrote, “I was almost crying because I was so upset at the nurse.”
How and to Whom Anger Was Expressed
Students expressed their anger most often to their fellow students and sometimes to their instructors. If the students were fortunate, the instructor helped them work through their distress by taking positive action: “My clinical instructor helped me report this to the charge nurse, who said she would take care of it.” More often, if the students wrote of reporting the problem to the instructor, constructive follow-up action was not part of the story. Several students, along with instructors, found excuses for the RNs. One student noted, “I have learned that working a 12-hour shift does involve physical stress, so I must always be careful in understanding that the nurses are especially tired at the end of a day.” At the very least, students might give the RN the benefit of doubt. One student stated:
I think that no health care provider would intentionally provide substandard care. I expect that there wasn’t time to better care for the patient, which is an issue I feel should be addressed.
Another student recognized her instructor’s empathy for the nurses: “My instructor suggested that I take further concerns to her since the RN was probably overwhelmed with patients that day.” Some directions from the instructors may have been misunderstood: “Going into clinicals, my instructor gave us little guidance and encouraged us to find things out for ourselves.”
For the most part, students wrote that they avoided direct confrontation with the RNs involved. Students wrote of feeling uncomfortable with and intimidated by the need to report negative events to the responsible people. To protect themselves, they avoided challenging a system that was still new to them. As one student pointed out, “It was only my second day at the hospital so I was unsure about how things worked.” Students also worried about the consequences of challenging the RN and said that they suppressed their feelings “to prevent worsening of an already bad day.” Students who did try to work through the problem by discussing it with the RN frequently were met with anger or dismissal. One student noted that when she went to the nursing station and related the circumstances in which she found the patient, the assigned RN responded, “I had no idea, but it’s no big deal; after all, isn’t that what you’re here for?”
All of the participating students recounted how they did not discuss their anger with the patients. For example, if the patients expressed guilty embarrassment about incontinence, the students tried to reassure them without assigning blame elsewhere. Feeling somewhat guilty about being thanked for providing care that they thought was “owed” to the patient, the students tried ignoring both the incident and the gratitude. One student wrote: “I didn’t say anything to him; I just changed the subject and began giving him a bath and talking about the weather.” They experienced some satisfaction when the patients themselves shared and validated the students’ opinion. One student commented, “It was apparent that my patient also did not approve of the nurse’s pessimistic personality since he stuck his tongue out at her once she left the room.”
According to the narratives, few of the situations were resolved to students’ satisfaction. There existed a residual distress demonstrated in part by the very selection of the story for this assignment. The negative feelings they had on behalf of the patients and those evoked by their own actions or inactions persisted. The following exemplifies a best-case scenario of a positive outcome:
After this experience was over, I still felt very angry at the nursing staff for being so negligent in providing care for this patient. I also felt very bad for the patient, because I know he was embarrassed about the situation even though I tried to reassure him that it was not his fault...Although this experience was a horrible one and I wished it had never happened, I felt proud of myself for handling it the way I did. Even though I was angry, I did not allow that to show when I was around the patient, which I believe is very important. I was glad that I was there to be able to help this patient.
Students who did not satisfactorily resolve the problem were more likely to write that they felt guilty or troubled. One student noted, “After the event, I felt guilty for not saying anything in the patient’s best interests,” and another student commented, “I still was troubled and could not stop thinking about it the rest of the day.” Students’ feelings about the nurses involved in the situations were clearly articulated; students expressed relief at not having to “deal with that nurse again,” a lack of trust in the RN’s judgment, and loss of respect.
In a bid to understand the meaning of the experiences, students often wrote of “lessons learned” ranging from actual physical care to interpersonal interactions and conflict resolution. Regarding the provision of care, lessons included the importance of both performing a complete physical assessment and “answering the patient’s calls as soon as possible in order to prevent something like that from happening.” Regarding the nurse-patient relationship, one student wrote:
You can’t take anything your patient says personal without knowing the full story, and even if you do, whether you like it or not, you are still obligated to treat them fully.
In the arena of conflict resolution, many regretted their decision not to confront the RNs involved. One student stated, “Rather than sitting back and doing nothing, I could have spoken up and had a chance to express my concern.”
The biggest lesson learned was self-awareness. In some instances, negative role models proved effective, eliciting comments such as, “I would like to believe that in my future practice that I will be more caring toward my patients.” On the opposite end of the spectrum of possible personal outcomes were comments such as “After the incident, I began to think that maybe it was not that big of a deal” and “I was pondering if I had made the right decision to be a nurse, since neither the nurse nor my instructor were advocates for the patient.” Perhaps the most poignant comment was:
I don’t know what it is like to be in her shoes, but I do know what kind of care I would like as a patient and she wasn’t providing it. I will always remember her as the nurse who taught me how not to work in the hospital.
For this group of students, anger provoked in the clinical setting related to their perceptions of negligence and disrespect. Primarily, the students’ anger was on behalf of the patients, especially patients who were unable to care for themselves. In addition to the anger, the plight of the vulnerable patients saddened the students. This blend of sadness and anger on behalf of another constitutes empathic distress (Hoffman, 2000). Empathic distress is an outcome of a process of role-taking in which the observer (nursing student) is capable of imagining how the victim (patient) feels. The observer reacts with sadness when the victim is experiencing discomfort or pain. If that discomfort is caused by another person, the observer feels anger toward the perpetrator (RN). This anger exists regardless of whether the victim feels angry. As we saw in the findings of this study, that anger was more intense and the observer was more indignant if the harm appeared intentional.
Empathic distress normally triggers helping behaviors (Hoffman, 2000). However, there is a reduced empathic tendency if the observer suffers anxiety about the consequences of interceding. In that case, self-focused distress outweighs other-focused distress. This failure to act may actually increase the distress, compounded by guilt, felt by the observer. For example, the students in this study worried about RN reactions and their own ability to “fit in.” The majority of students reported that they avoided direct confrontation with the RNs involved because they felt uncomfortable or unequipped to challenge those in authority. In turn, failure to confront the RNs evoked guilt about the present situation and anxiety when students contemplated what actions they would take in the future when facing similar circumstances. In addition, distress increased if students’ attempts to intercede were discouraged or rebuffed by either their instructors or the RNs.
Although providing the needed care for patients relieved some of the immediate distress, not fully addressing the issue resulted in a lingering residue of distress. It is this residue that may well sow the seeds of the escalating levels of moral distress found in everyday nursing practice. The cumulative effect of repeated episodes of empathic distress may take the form of self-protective indifference to the plight of others; in other words, the observer “turns off emotionally” (Hoffman, 2000, p. 200). Researchers have noted that nursing students and new graduates may become habituated to less-than-caring practices, gradually conforming to unit behavioral norms (Cameron et al., 2001; Greenwood, 1993; Ham, 2004; Hoffman, 2000). Hoffman (2000) noted that repeated episodes actually may intensify the observer’s commitment to help, in which case students become either more determined or more disillusioned in reaction to stress (Burnard et al., 2007; Curtis et al., 2007).
One worrisome aspect of this study’s findings entails the students’ perception of the relative invisibility or even absence of the clinical instructors. Vital to the students’ development as clinicians, the acquisition of affective skills requires as much facilitation and monitoring as psychomotor skills. Ideally, the clinical instructors and unit RNs (including managers) negotiate roles, responsibilities, and expectations before the students’ arrival. Instructors could emphasize the importance of first impressions and experiences, gently reminding RNs of their important role in the development of students into future professional nurses. Likewise, staff RNs could orientate instructors to the realities of priority setting in a world of scarce human resources and acutely ill patients. Together the instructors and RNs then could plan a safe environment in which students can ask questions and voice concerns. Explicit strategies covering who, what, when, why, and how of coping with stressful experiences would be mutually determined and provided to students.
As role models for the students, instructors and RNs actively advocate for patients by demonstrating assertive communication skills when dealing with perceived ethical breaches and the resultant justifiable anger (Shirey, 2007). As an advocate for the students, instructors provide a supportive presence and intervene on their behalf when appropriate. When necessary, instructors could designate clinical postconference time for “debriefing” and discussing unpleasant and distressing experiences. This also expands and formalizes peer support opportunities. Educators in both didactic and clinical settings may choose to implement evidence-based preventative interventions such as cognitive rehearsal (Griffin, 2004) or mindfulness-based stress reduction (Shirey, 2007). As one can imagine, these essential proficiencies carry serious implications for the selection and preparation of clinical instructors.
There is no doubt that students have positive experiences with powerful, caring RN role models. There are clinical rotations in which both RNs and instructors demonstrate understanding of the students’ needs, show interest, and explain how to care for specific patients. On those units, the nurses extend the concern and empathy that they feel for the patients to the students. Working together, both educators and clinical leaders have a responsibility to maximize these positive experiences by providing safe and nurturing work environments. The more careless and dismissive we act toward patients and students, the more empathic distress accumulates and the more distant students grow toward patients and the profession.
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