Duty of candour: supporting nursing students in practice: A support service at the University of Southampton has found students have an important role in improving the quality of care.
The publication of the Francis report has been described by health secretary Jeremy Hunt as a seminal report that will mark a turning point for the NHS. It resisted blaming individuals, focusing instead on what could be learned from the catalogue of appalling and tragic events, with an emphasis on developing the right culture of care within the NHS, through better leadership, training and transparency.
Among the 290 recommendations were calls for a stronger requirement for organisations and staff to speak openly and honestly when things go wrong. The duty of candour has now been placed on a stronger footing. No longer merely a contractual obligation, the non-fulfillment or obstruction of this duty would become a criminal offence.
But speaking out or raising concerns about practice is challenging and complex for professionals who have been working for years, let alone for a student on practice placement. The consequences for qualified health professionals are well known: there are professional and personal risks — demotion, reprimand, referral to psychiatrists, pressure to resign, careers halted, victimisation, ostracism, exclusion and bullying, disillusionment, isolation and humiliation. It requires moral courage, integrity, resilience and support, and the stakes are high.
For students on placement, there is often a strong desire to be accepted into the team. The need to affiliate and belong are powerful motivating forces. In order to avoid exclusion by the nurses they work with, students tend to obey, comply, work hard and generally attempt to present themselves in a favourable light. Where students feel unwelcome, alienated and unsure of their place in the clinical environment, they are more willing to conform and less likely to question poor practice.
However, our experience following the development of an enhanced support service for students within the faculty of health sciences at the University of Southampton, has been that students can and do feel able to report their concerns or assist placement areas in relation to adverse events, and are taken through the processes that may follow. This has included preparing them for, and accompanying them through the experience of giving evidence to investigating managers, disciplinary panels, safeguarding proceedings, and on occasion, being a witness in court proceedings, NMC fitness to practise hearings or an inquest.
Consistent positive feedback suggests that students can benefit personally and professionally from such collaborative support mechanisms. Placement providers welcome the approach and have told us that students have an important role to play in improving the quality of care.
The service also supports students who find themselves at the heart of an adverse event involving their own practice.
If a student has reported a significant concern or has been asked by a placement area to assist in their investigation of an adverse event, they are supported in the construction of a robust witness statement. This not only aids the investigation processbut insulates them from the potential rigours of cross examination. The new powers to be granted to the CQC to bring criminal prosecutions for breach of standards mean a higher standard of proof will apply of "beyond reasonable doubt", compared with the current civil standard of "balance of probabilities" so this is a particularly relevant feature of the service.
On reporting a concern into the faculty, designated staff with backgrounds in safeguarding, programme management, practice liaison and medical law, liaise with practice colleagues to investigate the claims and explore whether a local resolution through clarification of what has been seen may be required.
The outcomes of any subsequent investigation are fed back to the student, and actions, recommendations for measures to be taken are logged and monitored. Lessons learned from spent cases are then fed back into the curriculum, where there is a strong emphasis on values, advocacy, and human factors relating to adverse events. The support service is a collaborative effort between the faculty, our practice partners and the students. Ultimately, the acid test for students who have had the courage to raise concerns is whether or not they would be prepared to do it again.
Consistently, students have said that they would. Crucially, none of the students have had any difficulties gaining employment, and they have found the commendations they've received from investigating managers and senior NHS managers to be inspirational.
Diane Gow is academic lead for Student Support at Incidents in Practice at the University of Southampton Guardian Professional.
The publication of the Francis report has been described by health secretary Jeremy Hunt as a seminal report that will mark a turning point for the NHS. It resisted blaming individuals, focusing instead on what could be learned from the catalogue of appalling and tragic events, with an emphasis on developing the right culture of care within the NHS, through better leadership, training and transparency.
Among the 290 recommendations were calls for a stronger requirement for organisations and staff to speak openly and honestly when things go wrong. The duty of candour has now been placed on a stronger footing. No longer merely a contractual obligation, the non-fulfillment or obstruction of this duty would become a criminal offence.
But speaking out or raising concerns about practice is challenging and complex for professionals who have been working for years, let alone for a student on practice placement. The consequences for qualified health professionals are well known: there are professional and personal risks — demotion, reprimand, referral to psychiatrists, pressure to resign, careers halted, victimisation, ostracism, exclusion and bullying, disillusionment, isolation and humiliation. It requires moral courage, integrity, resilience and support, and the stakes are high.
For students on placement, there is often a strong desire to be accepted into the team. The need to affiliate and belong are powerful motivating forces. In order to avoid exclusion by the nurses they work with, students tend to obey, comply, work hard and generally attempt to present themselves in a favourable light. Where students feel unwelcome, alienated and unsure of their place in the clinical environment, they are more willing to conform and less likely to question poor practice.
However, our experience following the development of an enhanced support service for students within the faculty of health sciences at the University of Southampton, has been that students can and do feel able to report their concerns or assist placement areas in relation to adverse events, and are taken through the processes that may follow. This has included preparing them for, and accompanying them through the experience of giving evidence to investigating managers, disciplinary panels, safeguarding proceedings, and on occasion, being a witness in court proceedings, NMC fitness to practise hearings or an inquest.
Consistent positive feedback suggests that students can benefit personally and professionally from such collaborative support mechanisms. Placement providers welcome the approach and have told us that students have an important role to play in improving the quality of care.
The service also supports students who find themselves at the heart of an adverse event involving their own practice.
If a student has reported a significant concern or has been asked by a placement area to assist in their investigation of an adverse event, they are supported in the construction of a robust witness statement. This not only aids the investigation processbut insulates them from the potential rigours of cross examination. The new powers to be granted to the CQC to bring criminal prosecutions for breach of standards mean a higher standard of proof will apply of "beyond reasonable doubt", compared with the current civil standard of "balance of probabilities" so this is a particularly relevant feature of the service.
On reporting a concern into the faculty, designated staff with backgrounds in safeguarding, programme management, practice liaison and medical law, liaise with practice colleagues to investigate the claims and explore whether a local resolution through clarification of what has been seen may be required.
The outcomes of any subsequent investigation are fed back to the student, and actions, recommendations for measures to be taken are logged and monitored. Lessons learned from spent cases are then fed back into the curriculum, where there is a strong emphasis on values, advocacy, and human factors relating to adverse events. The support service is a collaborative effort between the faculty, our practice partners and the students. Ultimately, the acid test for students who have had the courage to raise concerns is whether or not they would be prepared to do it again.
Consistently, students have said that they would. Crucially, none of the students have had any difficulties gaining employment, and they have found the commendations they've received from investigating managers and senior NHS managers to be inspirational.
Diane Gow is academic lead for Student Support at Incidents in Practice at the University of Southampton Guardian Professional.
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