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Chapter 5 The demands of professional practice

At the point of registration, the Nursing Associate will be able to: understand the demands of professional practice and demonstrate how to recognise signs of vulnerability in themselves or their colleagues and the action required to minimise risks to health.

Case Study 5.1

I thought I would be able to handle it all, but after about eight months as a Nursing Associate I really started to struggle with anxiety, and I came to a point where I felt crushed and overwhelmed.

Oti was a newly qualified Nursing Associate working as a member of an assessment and treatment specialist service providing care for those with mental illnesses, who also have a diagnosis of a learning disability. This was a newly created post. When Oti commenced the job, her manager, a social worker, was less than complimentary about the role of the Nursing Associate, commenting to Oti how she felt being given an enrolled nurse to do a registered nurse’s job was not only unfair to her but to the patients also.

Joining the team, Oti was very much left to her devices as she had no preceptor, and few people (if any) understood the role and function of the Nursing Associate. Oti asked if she could, at the next team meeting, give a short presentation regarding the role of the Nursing Associate, bringing with her one of her lecturers from the university to present with her. On three occasions, the presentation was cancelled, and in fact, it never happened.

The service was being reviewed with plans to restructure provision. In the meantime, Oti came to work and was given several ‘tasks and duties’ that were commensurate with the role of a healthcare assistant. The job Oti came to do every day was far from the Nursing Associate job she had applied for and was successful in getting. After 3 months, Oti made an appointment to see her manager to discuss how she was getting on. The manager asked her to send her an email as she was too busy for a meeting. Oti complied with this. Three more months passed, and things had not changed. Oti was becoming despondent. She spoke with her staff side representative, who suggested a meeting with her manager. In the next three months, Oti had developed a number of niggling illnesses. She had recurrent colds, she had no self‐esteem, she felt she was letting people down, she was not sleeping, she was unable to switch off from her work, she dreaded having to go into work, she told her partner it was soul destroying, she found she was making silly mistakes at work such as inputting data incorrectly and on one occasion she had forgotten to make a follow‐up appointment for a service user; she felt she was being deskilled. The service user came into the clinic and verbally abused Oti, making physical threats. Oti went to see her GP, who said she was hypertensive, experiencing stress and was vulnerable. She was signed off sick from work.

Oti returned to work to find out the service had been re‐organised, and her new manager, also a social worker, conducted a welcome‐back‐to‐work meeting. A preceptor plan was developed, and a preceptor was allocated to help Oti achieve her future aspirations and to outline how she could become a fully integrated team member making a difference to the care of others. Oti and her preceptor meet regularly, and Oti is able to fully utilise her full scope of practice. She began to feel valued and that she was making a difference to the people she offered care and support to, and she is celebrating her achievements. Recently trainee Nursing Associates have been allocated to the clinic, and Oti is seen as a central resource and as a support to those who are on the same programme that she was on.

Top Tip

It is OK to not be OK. Seek help early, do not let anxieties fester and use all of the resources available including managers and staff side support, for example, your trade union or professional body.

Vulnerability

The NMC Standards of Proficiency for the Nursing Associate requires you understand the demands of professional practice and to demonstrate how to recognise signs of vulnerability in yourself or colleagues and to understand the action that is required to minimise risks to health.

Studying nursing is particularly hard: it involves trying to balance assignments, attending placements, working shift patterns, having a social life and, importantly, finding time for yourself. When registered, a Nursing Associate experiences other pressures that replace those faced whilst studying. Professional practice makes many demands. Regardless of the site of practice, on a daily basis the Nursing Associate engages with sensitive, intimate relationships, facing threats of violence and verbal abuse, grief and death. In some places of work, the atmosphere is enclosed; there are time pressures; a need to implement professional knowledge; excessive noise or undue quiet; sudden swings from intense to routine tasks; no second chance; unpleasant sights, sounds and smells and tense working relationships. These experiences and difficulties appear to be further exacerbated by a number of organisational issues which are instrumental in the stress process.

When the Nursing Associate is confronted by such events and tasks, it is hardly surprising that they report high levels of stress, and the physical and mental impact on the Nursing Associate can be detrimental to their health and well‐being.

Stress

Whilst there is stress in all jobs, in those careers dealing with human health, the importance of this issue becomes more sensitive and critical. Stress‐related factors can be considered as a predictor of caring behaviours.

The experience of stress represents a psychological state. It can come about as a result of exposure, or threat of exposure, to the more tangible workplace hazards as well as to the psycho‐social hazards of work. Those hazards of work which are associated with the experience of stress can be termed stressors.

When applied directly to nursing, a situation which is typically experienced as stressful is seen to involve work demands which are threatening or which are not well matched to the knowledge, skills and ability to cope of those involved; or work which does not fulfil their needs, especially where those nurses have little control over work and where they receive little support at work or outside of work.

Recognising vulnerability

Occupational stress negatively affects the Nursing Associates’ health‐related quality of life; it renders the Nursing Associate vulnerable and can influence patient outcomes. Job‐related stress can result in loss of compassion for patients and increased incidences of practice errors, and as such is unfavourably associated with the quality of care.

Verbal or physical abuse can have negative psychological effects that persist after the incident.

With regard to physical health, work‐related stress is linked with many physical health problems including migraines, musculoskeletal pain, long‐term physical illnesses, hypertension, irritable bowel syndrome and duodenal ulcer, and immune and endocrine system illnesses.

Psychiatric morbidity is also associated with occupational stress, at an emotional level. It has been correlated with anxiety, dysthymia, low self‐esteem, depression and feelings of inadequacy. See Case Study 5.1, which outlines the experiences of a vulnerable Nursing Associate who struggled at work to cope.

Responding to stress

In responding to stress and the damaging effect it can have on the Nursing Associate and care outcomes, it is essential to acknowledge that stress has the potential to make the Nursing Associate vulnerable to ill health.

The ability to cope with the demands and stress from work may be improved with specific occupational health education and training programmes that enhance knowledge and ability. The approach must address both the individual and the organisation. Facilitation and verbalisation of feelings and experiences, teaching relaxation techniques, conflict solving and positive reappraisal may help with regard to stress response modification and stress coping. Interventions at an institutional and organisational level (employers and universities), including additional managerial support and staff recognition policies, may be helpful in work environments to prevent stress on a primary level. When dealing with stress, knowing where to go for help is also important.