Pakistani Student Nurses’ perceptions of their hospital’s health professionals’ attitudes and suggested ways to improve patient care – An untainted view

Background & Objectives: Feedback brings a fresh perspective and improvement in any organization. Health professionals (HPs) lose insight of the gaps in medical care. The views of student nurses can help improve systems. The objective of this study was to assess the views of our student nurses and how they perceive the way the doctors and HPs work in our hospital and comment on training, attitudes, care pathways, teamwork, and what needed to be improved. Methods: A proforma based qualitative study was carried out at the Nurses’ Training Centre of PAF Hospital and Fazaia Medical College, Islamabad, from January to March 2020. After approval, a semi-structured proforma with open and closed ended questions was administered, in English and Urdu. The results were analyzed by comparative numbers and percentages for each question and descriptive responses were grouped in recurring themes and analyzed for content and their constructive value. Results: Out of 85 nursing cadets, the proforma could be administered to 61(M=38(62.3%) and F=23(37.7%). Most were FSc with 26% graduates. Majority of the female students’ main reason for joining was to serve humanity, unlike most males. According to gender many responses were interestingly different. Majority of females thought male doctors were better (86%). Only 36% said the doctors were sincere in care of patients. Most thought that we needed to improve patient counseling. Most thought the seniors treated them unfairly, but bullying was negligible. They wanted the senior HPs to improve their attitudes and ensure adequate equipment in the wards. They were worried about personal security from patients and relatives. Dedicated mental health services to deal with stress of witnessing every day misery and death was suggested. Conclusions: Doctors need to improve their counseling skills and should talk more to the patients and their relatives. They should acknowledge the nursing students and improve teamwork. Belittling them in front of others harms their self-efficacy. Simple corrections like punctuality, ownership of their patients and improvement of equipment and systems can improve patient care.


INTRODUCTION
One of the greatest strengths of Nurses training all over the world is their direct involvement in the care of the patients almost from the very first day. 1 They have lectures, usually, in the morning and then perform supervised duties in the wards, doing regular shifts, including night duties. This is Correspondence: Prof. Chaudhry Aqeel Safdar, FRCSEd Fazaia Medical College & PAF Hospital, Margalla Road, E-9, Islamabad, Pakistan. E-mail: aqeel_safdar@hotmail.com very different from the medical students training who spend nearly half of their training hours in the class rooms or labs. It also gives the nurses a unique, untainted perspective about the way the patients are treated in their hospital and about those who provide this care. They have not been exposed to the somewhat cynical world of medical profession and their "war (d)-hardened" seniors with their lessening empathy. 2 As many of us have observed, and has been proven, that the newly inducted health professionals are motivated, empathetic and altruistic. But over the years they lose these essential qualities. 3 This loss of empathy in health professionals (HPs) and medical students occurs in the clinical years; more so during house jobs and training years. Many reasons have been given and ways to improve proposed. 4 These HPs in training are silent and often invisible soldiers of medical profession and are in a unique position to sense and observe the way we work and what needs to be improved. 5 Feedback from lay people or juniors often brings a fresh perspective and improvement. These feedbacks have content, construct and predictive validity. 6 After years of working in the harsh hospital environments and being "battered" by the physical and psychological salvos, the 'touch' withers with loss of empathy. 7 They are patients' advocates, and hence should be encouraged to contribute in the care, a system practiced in UK, although not so much in German system. 8 We sometimes get entrenched in our own set archaic ways and views from these new nurse students may provide a fresh insight of our training and care shortcomings. 9 It may be useful to harness the views of these early years of the new nurses, who perhaps know more about the way doctors and other HPs work and deal with their patients, thus improving our patient care and the way we deal with these junior-most, but key players of our teams. 10 Based on the above surmises, the objective of this study was to administer a survey to our student nurses and assess their views about how they perceive the way the doctors and senior HPs work in our hospital. The emphasis was to comment on attitudes of HPs regarding training, care pathways, teamwork, and what needed to be improved.

METHODS
This was a proforma based qualitative exploratory study conducted at the Nurses' Training Centre of Pakistan Air Force (PAF) Hospital and Fazaia Medical College, Islamabad, from January to March 2020. Approval from Institutional Review Board (IRB/01/3/07/2020) was obtained. A semi-structured proforma with simple open and closed ended questions was administered. The questions were both in English and Urdu, and replies could also be in both languages (Annexure-1). It was anonymously filled and consent taken.
The first section of the proforma noted the demographics and education with the basic baseline questions to provide a general background of each cadet. This helped to provide a better understanding of this cohort, and hence correlate with their perceptions. Then there were sections about their views and perceptions regarding: 1, the doctors they worked with; 2, the senior nurses and administrative staff, commenting on their attitudes and what needed to be improved; 3, what needed to be improved in the hospitals and patient care; 4; lastly, a section for free expression of views (Annexure-1).
The results were analyzed by finding percentages and frequencies for numerical variables, or as frequency or percentages for categorical variables for each closed question and descriptive responses of open ended questions were grouped in recurring themes and analyzed for content and their constructive value. They were also cross-analyzed for correlation with gender and other demographic information provided, using Microsoft Excel.
Frivolous responses and personal problems were identified but not included in the evaluation reports. Although they were shared with the tutors to determine their nature and address appropriately, ensuring that their genuine grievances are heard. 11

RESULTS
At the time of study, there were 85 nursing cadets of PAF Medical Services enrolled. The proforma could only be administered to 61 of them, the rest being on temporary duties or leave. The sex ratio was M=38(62.3%) and F=23(37.7%). A summary of their demographics and basic data are given in Table-I. Some of them provide interesting facts, which may give insight into their backgrounds and responses.
At the end of the Q 3 (what do the doctors of our hospital need to improve), Q 4 (what do they think about their own nursing seniors) and Q 6 (Anything else you want to say) it was encouraged to give free opinions. The main themes, answers and the percentages are given in Table- Table-III. The nursing cadets also mentioned some administrative problems related to the service. These were noted and conveyed to the senior administrators separately. They included points like: excuse of non-clinical duties, separate rooms for admitted staff in the hospital, and some others.

DISCUSSION
The first section of the proforma explores the demographics of our cohort of the newer nurses, which has been found to be useful 12 and presented some interesting information (Table-I). It is crucial to inspect the socio-demographics which can affect the validity of any survey. 13 These were all uniformed nursing students of the PAF nursing services. In our study, 68% had completed their higher secondary school certificate (FSc), with 26% graduates and only 6% were matric (O-levels equivalent), while a decade ago in a study from Karachi had 78% of their nursing students with matric and only 20% FA/ FSc, while only 2% were graduates 14 ; 90% of our nurses had achieved first division in their exams, many missing entry into a medical school by only a few marks. Hence the intellectual importance of the responses to the survey questions. 15 Most of them were from Punjab and KPK, the northern provinces of Pakistan, one from Baluchistan and none from Sindh. This was expected as those from the southern provinces would have gone to the Karachi institutes. Fathers of most of them (70%) were government servants or from armed forces, hence their liking for joining the PAF. They came from families with average number of siblings at 4.6, medium sized by our country's average, with girls coming from bigger families. This supports the surmise that they would be able to support the family income. Another reason could be to secure a better marital proposal. In India, which is one of the biggest suppliers of trained nurses to the Middle and Far East, this has been quoted as an important factor for joining the nursing profession. 16 The Question 1 in the survey asked why they wanted to join nursing in the PAF (Table-II). Altruistic motives of serving the humanity were stronger in the females (M vs F, 50% vs 72%). Forces uniform has always attracted young people, and 82% of the girls considered this to be one of the reasons for making this decision. Many boys and girls came from the village backgrounds and joining PAF is a good reason to escape the village life, but in our survey none of the boys or girls quoted this to be a reason (0%). Obviously with more and varied job opportunities available, coming to nursing was a considered choice. A change from previous studies. 16 Question 2 was important and asked the views of the students regarding the doctors, with whom they worked. Overall they thought the Consultants were best 'doctors' (87%), compared to House officers-HOs 23% and Trainees-TRs 17%. This can be ex-  pected as the expertise of Consultants was an obvious choice for being selected. About 86% of female students thought that male doctors were better at their job, as compared to only 37% of male students. This gender bias which has been observed previously in other studies as well. 17 However, only 36% thought that the doctors were sincere in their job, a disconcerting finding. Another important question was about the attitudes in dealing with the students themselves. In spite of the fact that the consultants were considered the best doctors, the HOs had the best attitude and working relationship with nurses. The consultants ignored them, and this made the teamwork less than optimum. Consultants, as leaders, have to acknowledge the student nurses and make them a useful part of the teams in the care of the patients, which has been reported. 18 Another aspect pointed out was the punctuality, which fared very poorly, trainees and HOs being the least punctual. This is something which needs to be inculcated  early into the young doctors, as previously shown. 19 We also asked which departments were the best and in the order of merit, they were Paediatrics, Medicine, Surgery and Cardiology. Other major departments like Gynaecology, ICUs, Theatres, ER and diagnostics need to reflect on the reasons for this and this was conveyed. When asked in Question 3, what the doctors need to improve; an overwhelming majority wanted the doctors to improve the way they talk to the patients, and to be polite. This has been pointed out by so many studies which emphasize the need for empathetic communication skills. Mindfulnessbased empathy training (MBET) leads to an increase in empathy. 20 Punctuality was again found to be lacking, which can perhaps be improved by better role modeling and better institutional culture. 19 Again the female students thought that female doctors need more improvement. They also thought that doctors should be nice to student nurses in the wards and 86% wanted to be appreciated for the work they do, which helps in team building, motivation and self-efficacy of the learners. 15,21 Question 4 addressed the attitudes of the senior nurses, tutors and managers. Majority thought that they treat them badly (73%) and unfairly (61%). During the feedback bullying was another direct question which was asked. Bullying is a critical issue, since it is linked with nurse attrition and eventually to their morale. 22,23 Bullying also negatively affects victims' social relationships inside and outside the institution. 24 11 This has not been proven by this study, a credit to the institutional culture. Unstructured and one to one teaching was also found to be lacking. A good learning environment is dependent on engagement and collaboration between preceptors and academic nurse teachers. 15,25 To produce a relaxed, empathetic, competent and confident HPs the institute needs to provide congenial and friendly educational environment. 26 Work motivation among nurses is a crucial tool to manage nurses' shortage, retention, migration and work leave. 27 Question 5 was important to know, holistically, about the important aspects of improving the hospital care. Almost all (92%) thought the patient care needs improvement. We expected that having more doctors and fewer patients would receive a yes vote. However, only 22% and 39% thought this was necessary. Most wanted doctors to do better (62%), better nursing attitudes (67%), more equipment (72%) and improving in-patient care systems (71%). This was a most insightful assessment from such a young group and reported from other studies. 28 The last part of the survey asked for free comments (Table-III). One theme was to give any harsh feedback separately and not in front of the patients. It belittled them. This decreases confidence; better techniques can be used. The 'feedback sandwich technique' provided at the bedside are most useful to the student's learning. 28 The second important theme was that doctors lack in the way they communicate with the patients and their relatives. The teams discuss the disease at length with each other but do not involve the patients and their carers in the discussions. They also need to care for the private and public patients equally, and irrespective of the status; a simple observation which senior doctors need to reflect on. 29 The section 6 of the survey was an invitation to give free comments. It was mentioned that, not only the HPs of the hospital, but the patients and their relatives also need to follow a code of ethics. This should be implemented and unruly behaviour should be checked immediately to prevent from escalating. 30 Some other comments about doctors' practices were also insightful. In some wards the rounds were carried out by different doctors every day. This often caused confusion about their main doctor. Regarding the nursing care, clear defining of roles of each member of the ward team was pointed out. This effects job satisfaction, role conflict and ambiguity. 31 The provision of psychological support to student nurses was also mentioned. A dedicated service for them to deal with their day to day to psychological trauma of death and suffering has to be in place. 32 In the recent COVID pandemic more than one suicide could have been avoided. 33 Some valid suggestions on the day to day running of the wards were provided to the administrators who welcomed and tried to address them with fruitful outcomes.
It is surprising how these young student nurses provided such astute observations which were equal to some high powered and expensive studies. Today's students are wise and observant, and are not afraid to participate in improvement of the patient care. Information from such questionnaires can provide timely feedback and enable administrators to identify and correct organizational factors. 34 If only we would listen to them actively.

Limitations of the Study:
This being first study of its type, it has some limitations. The study was conducted in one nursing institute and therefore, the findings can only be used to this specific participant group.

CONCLUSION
Doctors need to improve their counseling skills and should talk more to the patients and their relatives. They should also acknowledge the nursing students and take them along to improve the teamwork. Belittling them in front of others on the ward harms their self-efficacy and capacity to function maximally. Simple corrections like punctuality, ownership of their patients and improvement of systems can enhance the quality of care.