Health and Wellbeing: A Student Nurse's Perspective

Submitted by Jordan Louise Balfour

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Health and Wellbeing: A Student Nurse's Perspective

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Gray and Dier (1992) state that the health and well-being of student nurses is of upmost importance when considering their inexperience in the field, the demands of the course and profession, as well as the implications for patient care. However, Morrissette (2004 p535) suggests that although student nurses may acknowledge their own personal issues which affect their own health and well-being, they are likely to deny them because “they consider themselves providers and not recipients of care”. This essay will therefore consider and discuss how my holistic health and well-being has been influenced by different factors since starting higher education. In particular, it will focus on the effects of unsupportive mentors on student nurse health and will draw on the concepts of self-esteem and stress to explore this topic in depth. In doing so this essay will demonstrate that health is a multifaceted concept which is unique to every individual and subjective to a number of different factors.

Stickley and Timmons (2007) suggest that the term ‘health’ holds many theoretical and diverse meanings which are dependent upon individual values, beliefs and knowledge. It is expected that student nurses entering higher education hold lay beliefs of ‘health’, however, it could be argued that all approaches to the concept of ‘health’ should be considered in order to be able to appreciate and support the conceptual views of service users (Stickley and Timmons 2007). By asserting their superior professional position and focusing only on their personal view of ‘health’, nurses can effectively silence the views of the service user and determine the potential for recovery (Stickley and Timmons 2007). This statement is supported by Szasz (2004 p65) who states “Define or be defined, the struggle for definition is the struggle for life itself”.

It is suggested by Ivanitz (2000 p52) that bio-medical model definitions of health focus on “the physical manifestations of illness”, whereby the body and the mind are separable entities and illness resides in either one or the other. For example, Herzlich (1973 cited Bishop and Yardley 2010 p272) describes health as “simply the absence of illness”. Halfon et al (2014 p344) state that bio-medical models drove the first era of healthcare, leading service providers to focus on “the treatment of acute illness, injury, and infectious diseases”. Levisohn (1989) suggests that although the bio-medical model is still in use and despite many technological advances, today’s reflective service providers identify, more than ever, the limits of such products and the significance of a patient’s drive towards health in ultimately overcoming disease. Ivantiz (2000) argues that if health providers approach health bio-medically, there is a risk that patients become dehumanised and their holistic needs remain unmet, resulting from the power imbalance that renders the patient as a ‘lay’ participant and the practitioner as an ‘expert’. Illich (1976 cited Ivanitz 2000 p52) supports this idea by stating that the bio-medical approach “has the authority to label one man’s [sic] complaint a legitimate illness, to declare a second man sick though he himself does not complain, and to refuse a third social recognition of his pain, his disability and even his death”. Tomljenović (2014) suggests that although medical knowledge and technology is advancing and facilitating the extension of life span, people are not proportionally less unwell. The bio-medical approach causes practitioners to focus on curing symptoms without investigating the causes behind disease, therefore the disease appears again or becomes chronic, ultimately reducing quality of life and well-being (Tomljenović 2014). Another criticism of the bio-medical approach is that it seeks to define health by norms, suggesting that anyone who is physically or mentally weakened is not healthy, but does not take into account whether individuals themselves feel unwell or that their function is impaired (Misselbrook 2014).

As well as the absence of illness, Hughner & Kleine (2004 cited Bishop and Yardley 2010 p273) suggest that health can also be defined as “the ability to carry out daily tasks (to do health) and positive vitality or wellbeing (to have health)”. In comparison to the bio-medical model, it could be argued these approaches give focus to positive abilities and characteristics rather than the absence of physical problems. An approach which focuses on ‘positive vitality’ and is similar to the bio-medical model in terms of ‘weakness’ is Williams’ (1983 cited Bishop and Yardley 2010 p272) who suggests that being healthy relates to “having strength and resilience (and not having weakness or exhaustion)”. Williams (1983 cited Bishop and Yardley 2010 p272) also provides a description of health which focuses on an individual’s ability to be “functionally fit for work or activity, for one’s normal obligations”.

Halfon et al (2014 p344) suggest that of recent, an idea has developed to suggest that health “begins before conception and continues throughout the lifespan”. This idea is supported by Antonovsky (1987 cited Levisohn 1989 p1307) who proposes that “health should be viewed as part of a continuum”. A study conducted by Kermack et al (1934 cited Russ et al 2013 p497) which supports this theory concluded that the expectation of health development during the life-course was “determined by the health of the mother and the conditions which existed during the child’s early years”. The ‘life-course model’ of health challenges both the ‘bio-medical’ and ‘multiple-risk factor’ model by stating that an individual’s course of health amounts to more than “a combination of her genetic endowment and adult lifestyle choices, and that social, psychological and environmental factors operating early in life could have major impacts on both short and long-term health outcomes” (Halfon et al 2014 p345).

The holistic or ‘multi-risk factor’ approach suggests that the health of an individual is dependent upon a range of internal and external components, such as the body, mind and environment, which are interdependent but contribute equally (Supranowicz and Paź 2014). Similarly, the World Health Organization (WHO) (2015) offers the definition that “good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity”, suggesting that threats to health are derived from complex interactions among a range of holistic factors (Ashcroft 2011). Although this definition developed by WHO continues to be pervasive in its influence, it could be argued that it is an unattainable ideal as it incorporates ‘complete’ wellbeing under the concept of health. Misselbrook (2014 p582) suggests that no person is in a complete state of wellbeing, therefore “we are all in need of medical intervention to correct ‘abnormalities’”. It could be argued that the WHO definition is a combination of both the ‘bio-medical’ and ‘social humanistic’ perspective as it focuses on both the absence of disease and the ability of the individual to function ‘normally’ in all dimensions. The ‘social humanistic perspective’ focuses on “the consequences or impact of a disease or disorder on an individual’s daily life” (Lundstrӧm 2008 p393). Lundstrӧm (2008) gives support to this theory by suggesting that within the rehabilitation context, a medical diagnosis alone is not always adequate, therefore “information about the consequences or impact of a disease or disorder on an individual’s daily life is needed” (Lundstrӧm 2008 p393).

Downey and Chang (2013 p819) state that ‘lay beliefs’ are “implicit mental representations of phenomena held by everyday people” and “focus on coherent description, rather than explanation of unseen processes”. It has been suggested by Ewles and Simnet (1999) that the concept of health adopted by an individual is formed by their knowledge, values, life experiences and expectations and this has implications for behaviour. Bishop and Yardley (2010) argue that the definition of ‘health’ an individual adopts, will influence their view of what health is and provide important indicators of ‘wellness’. For example, if an individual believes that ‘health’ is the absence of illness, not being ill is an indicator of being healthy. However, Kaplan and Baron-epel (2003 cited Bishop and Yardley 2010) state that an individual’s concept of health can fluctuate depending upon current health status and suggest that people who rate their health as poor may emphasise negative indicators of health and vice versa. In contrast, Bishop and Yardley (2010) suggest that individuals can hold a number of beliefs towards health and the extent to which these beliefs are held, influences how the individual adapts to illness. For example, Bishop and Yardley (2010 p283) state “having a chronic illness and seeing the presence of illness as an important indicator of wellness would imply a perceived inability to have or be able to strive towards wellness whereas placing more emphasis on functional indicators of wellness allows a person to have an illness and yet consider themselves to be well in other ways”.

Though the term ‘health’ is commonly used, Williamson and Carr (2009 cited Song and Kong 2015 p1097) note that “its definition is still very broad, ambiguous, complex, various, and multidimensional”. It could be argued that there is no ultimate definition of health because the concept is personal and therefore each and every individual defines ‘health’ by the way that they perceive it. As a result of this discussion, I have offered my own definition of health which states “Health is a flexible and positive concept which is uniquely defined by each person depending upon their personal values and beliefs, and is subject to change through different stages of life. To be healthy is to feel content in all dimensions (physical, emotional, spiritual, social, environmental, and intellectual) of one’s being, at a level which enables an individual to function and succeed in their own life”.

Since the beginning of the academic year, my holistic health has been influenced by a range of factors. My physical health was compromised during my first placement as I became unwell. Whilst attending placement I had very little time to rest and as I did not want to fall behind on the hours I had to achieve, I chose not to call in sick and therefore did not give myself the extra time I needed to recuperate. As a result, the infection I had worsened and it’s time period was extended, I gained further infections and suffered from a vasovagal attack during practice. Although I chose not to call in sick, I was told to go home on a couple of days during my placement in order to protect both myself and the patients on the ward, and this took a toll on my psychological health. As I was already aware that I was falling behind on the hours I needed to achieve and I was approaching the end of my placement, I became very stressed and worried about making further hours up due to being sent home against my will. The thought of having to spend more time in my placement was a stressor in itself, as the team I worked with were often unfriendly and unsupportive which had a direct effect on my self-confidence and motivation. The combination of academic work and working full time hours on placement also affected my social health as I had limited time to spend with friends and family. This once again had an effect on my psychological health as I became deeply saddened by the fact that I could not spend as much time with certain people as I wanted at a time where I felt I needed company the most.

Nursing students’ first clinical placement experience is considered to be of critical importance within their educational and professional journey, however, studies have shown that for some nursing students, “perceptions and experiences are markedly at odds with the desired outcome” (Levett-Jones et al 2015, para 21). There is much evidence to suggest that for student nurses, clinical placements are substantial sources of stress (Morrell and Ridgway 2014) and one significant contributing factor is an ‘unfriendly and unsupportive atmosphere’ (Evans and Kelly 2004). Nolan (1998 cited Lamont et al 2015) notes that staff behaviours and attitudes may be the most important factor when considering a nursing student’s placement experience and the development of his/her efficacy, confidence and competence. During my first placement, I felt very unwelcome and unsupported by many of the staff on the ward; in particular, my associate mentor. Although it is implied that mentors should offer support and guidance, as well as a willingness to share their experiences (Duchscher 2001), I felt that my associate mentor displayed a thorough disinterest in facilitating my learning through a lack of interaction with me and failure to include me. For example, my associate mentor often failed to acknowledge me when I communicated with her, left me to carry out tasks by myself with no instruction and acted as if she had no interest or time to include me in what she was doing. Henderson et al (2007 cited Lamont et al 2015) support this statement by citing ‘unsatisfactory working relationships between mentors and students’ and ‘exclusion from ward activities’ as reasons for disappointing placement experiences.

Reid-Searl and Happell (2011) argue that the support and supervision of nursing undergraduates is integral to their placement experience, however, Warne et al (2010) suggest that many students cite ‘a lack of engagement and clinical support’ when discussing unsatisfactory placement experiences. Lamont et al (2015) argue that the concept of ‘belonging’ is central to a student’s positive experience as it demonstrates an interest in their learning, allowing them to feel supported and concentrate on nursing skills as opposed to figuring out how to ‘fit in’ with staff. During my placement I felt excluded from the nursing team and as a result of this, I spent much of my time trying to fit in with them, in hope that they would take an interest in me and begin to include me. My perceived inability to fit in with the staff combined with my limited participation in patient care and ward activities consequently resulted in a decrease of my self-confidence. In support of this statement, Chesser-Smyth and Long (2013 cited Levett-Jones 2015) suggest that students suffer from an ‘erosion’ of self-confidence when they feel undervalued by the team. Nolan (1998 cited Lamont et al 2015) also argues that skills and confidence cannot be developed without support and involvement in direct patient care.

The apparent negative attitude and resulting behaviours that my associate mentor had taken towards me had a direct effect on my psychological health, in particular, my self-esteem. Wang et al (2010) suggest that during their first placement, students who are unsupported by their mentor and consequently struggle to adjust to their role are at risk of diminished self-esteem. Lindop (1989) noted that 60% of single reasons for student nurses deserting their training were related to resultant feelings of negative staff attitudes, supporting Randle’s (2001 cited Evans and Kelly 2004) conclusion that staff nurses have an extremely influential effect on student nurses self-esteem. Like the concept of ‘health’, the concept of ‘self-esteem’ has many definitions, such as “the extent to which we believe ourselves to be capable, significant, successful and worthy” (Edwards et al 2010 p82). Though there are many views on how the ‘self’ is constructed, it could be argued that Baumeister & Tice’s (1990 cited Randle 2003 p51) theory is most relevant to me as they suggest that “for many people, the influence of the external environment is so great that self-esteem is shaped via being accepted by others”. My mentor’s disinterest in me and my learning and her inability to teach lowered my self-esteem, causing me to lack self confidence in my ability to carry out even the most basic of nursing procedures and made me feel that I was unworthy of her time. This statement is supported by Rosenberg (1985 cited Burnard et al 2001) who noted that people with low self-esteem tend to be self-critical, lack confidence and consider themselves less worthy than others. Although there is much evidence to suggest that diminished self-esteem is common throughout nurse training, Burnard et al (2001) state that the quality of care a patient receives is dependent upon the nurse’s self-esteem, therefore nurses must feel ‘comfortable’ with themselves if they are to encourage, care for and help others.

Lazarus and Folkman (1984 cited Burnard et al 2001) argue that an individual’s self-esteem is an important predictor of how they adjust to stress. Cohen et al (1995 cited Galbraith et al 2014 p171) suggest that stress occurs “when the demands placed upon an individual exceed their perceived ability to cope”. Peters et al (2015) note that although placements provide obvious benefits to students, poor working relationships between mentor and student, a lack of supervision and support, as well as environments that fail to promote ‘belongingness’ are all central factors which are associated with elevated stress levels. Yonge et al (2002 cited Li et al 2010) suggest that student nurse stress can produce an inability to learn, integrate and perform successfully, resulting in low quality patient care and psychological and emotional distress, therefore, it is necessary to identify effective coping skills quickly in order to deal with future clinical stress (Sarafino 1998 cited Evans and Kelly 2004). Watson et al (2009) claim that although student nurses cannot avoid stressors, their personal ability to cope with stress is imperative in relation to academic success and clinical competence. Furthermore it has been suggested that, while academic and clinical success is important, students' “emotional wellbeing, resilience and self-care” is paramount, as stress can affect all aspects of students’ health and therefore jeopardise safe practice (Lee et al 2007 cited Shaban 2012 p204). During my placement, my self-confidence and self-esteem was very low which made coping with stress particularly difficult. In support of this statement, Mruk (1999 cited Edwards 2010) proposes that low levels of self-esteem expose individuals to the negative impacts of stress and cause them difficulty in managing the demands of the course, as well as the development of therapeutic relationships with patients. The stress that I encountered, as a result of feeling unwelcome and excluded, caused me to experience difficulties with sleeping and consequently, I suffered from increasing exhaustion throughout my placement which eventually had an impact on my physical health. Killam and Heerschap (2013) state that student nurses are particularly at risk of exhaustion and thus infectious diseases as a result of stress-induced changes to the immune system.

While the profession that I am entering is fulfilling, there is much evidence to suggest that it is also an emotionally demanding and stressful occupation, which therefore requires myself as a student nurse to practice and maintain good self-care in order to be protected against emotional exhaustion and burnout (Levett-Jones 2015). Although it has been suggested that stress is a normal part of a nurse’s working life, prolonged or elevated stress can have a long-lasting effect on nurse health which may also impact upon patient health (Wright 2014). This statement was highlighted by the Francis inquiry (2013) which specified that an increase in the stress level of nurses had been linked to a decline in care and compassion within healthcare. While it is implied that both students and nurses cannot avoid stress, the effects of stress on their health and how they adjust to stress is dependent upon the adequacy of their coping behaviours (Seyedfatemi et al., 2007 cited Shaban et al 2012).

In conclusion, this essay has demonstrated that health as a concept is multifaceted, consisting of numerous definitions which depend upon a range of factors that are relative to the individual. This essay has also discussed a range of factors which have influenced my holistic health and wellbeing since the beginning of the course and in particular, has identified how an unsupportive mentor on placement became the most salient negative influence upon aspects of my health. Furthermore, this essay has considered and demonstrated many implications for nurses relating to how the concept of health is defined and the importance of maintaining good health and wellbeing for both students, nurses and consequently, patients.

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