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Fear and decision making in the nursing discipline (letter)

Matt Reed's recent blog post ("That, and the NCLEX: A Response to Steven Mintz"), itself a response to an earlier blog post by Steven Mintz, spurred some ruminations on related observations I've made about the impact of the existing structures and practices within the field of nursing. My peripheral experience in working with individuals in this discipline is that the same two factors mentioned by Reed, clinical placements and NCLEX pass rates, can result in an intense fear that may drive decision making in unhealthy ways. Conversations with colleagues and friends suggest this is not isolated.

Perhaps the most disturbing implication is the marginalization of underrepresented populations, especially students with disabilities. If a supervisor at a clinical site perceives a student's needs to be burdensome, it may impact that person's willingness to accept additional students from the institution. Similarly, accommodations for third-party examinations may be more difficult to control and monitor than accommodations for instructor-developed assessments, leading to fear of a negative impact on pass rates. In dire need of clinical placements and good pass rates, administrators may feel torn between what is right and just for individual students and what will sustain the program.

Additionally, innovation can be seen as incredibly risky, particularly if things are going relatively well. Just desiring to bring the discipline into alignment with what other disciplines or institutions are doing can lead to difficult conversations. The same individuals who are striving to avoid perceived risks may simultaneously be requesting exceptions and customizations to a host of policies and practices of the institution. It appears as if no institutional decision, big or small, or even seemingly tangential, can be accepted without questioning the impact on clinical placements and/or NCLEX pass rates.

Let me be clear. I'm not questioning the compassion or motivations of people in this field, individually or collectively. I have had personal experiences with excellent nurses and they have had a powerful impact on my life. I also have great relationships with many people who work in this discipline. This is not intended to be a criticism of individual decision makers, many of whom are well aware of the unhealthy tension.

What I'm wondering is if there might be systemic issues worth exploring more broadly. It is possible that national organizations for the field may already be considering such issues; I wouldn't know. It is also likely that I don’t have a sufficient understanding of the complexities of this field. From an outsider’s perspective, however, it sure feels like additional consideration should be given to the impact of broader structures and policies on decision making at the ground level. I’d be interested to read other perspectives, particularly from those who may be more knowledgeable about this field (or related fields) than I am.


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