Working environment

One of the positive aspects mentioned was that students felt familiar with the expectations of the facility, which led to mutual respect.

In the military, I will say that in the military institutions, here in the hospitals, there is mutual respect because you know what you should do. You know

what to expect. (FGS1–3:76,77)

Participants also agreed that compared with the civilian facilities, the working conditions were better and so were the service delivery and the patient care.

I told her, ‘I am in the military and it is so different because we train under people with a positive attitude unlike in the public sector, we take good care of our patients, our working conditions are better, so even the service we

deliver is up to [a] good standard. (CIN–1:13)

Participants mentioned that, as they were in a cultural diverse environment, they had to learn to accept and respect patients and colleagues from all cultures. A degree of cultural incompatibility did however exist, which made it difficult to get along. It was also mentioned that culture played a role in terms of favouritism.

So, basically, I am going back to the issue of culture. When you go through a military, you meet all these different kinds of people. Not all of you, you are

going to get along. (FGS2–1:266,267,268)

So with that, being a soldier and anybody being a nurse that you have to firstly try to understand or accept the fact that all of us we have different cultures. Then by doing so, you have to learn to respect those cultures; because when you are a nurse you deal with different kind of patients on a daily basis and most of the time they differ each day. So if you don’t understand or you don’t want to respect someone else’s culture, it is going to be difficult as a nurse to care for the individual because basically you don’t

care how do they feel. (FGS2–1:2,3,4)

In my case you will find that if the in-charge in the unit for that time is of the Sotho background and I also am, then we get along just fine compared to

other of the different background. (CIN–3:50)

Participants indicated that they experienced the military clinical learning environment as being rigid and constrained in the sense that they felt that their opinions were not required, and that they were not allowed to speak up or use their own initiative. They further indicated that this prevented them from reaching their full potential as nurses.

… if you are a student, it is like you are nothing. That is how I felt it or maybe my experience. It is like, you are nothing at all. You can’t say anything or you don’t know much. The doctors here would … it is only a few of them that will

take your opinion, ask you what you think or something like that. (FGS1–

1:162,163)

… they tell you, ‘No, you are a student, you don’t know anything’. In that way, they don’t motivate us. At least when we are in the clinical they must give us that thing the students are here to learn, let’s give them an opportunity to

voice out their opinions. So, they make it difficult for us. We can’t even …

Sometimes you go to a ward and you leave without even learning. (FGS2–

6:16,17,18)

Basically, since we are supposed to develop and gain knowledge and experience from whatever we are doing, be it gaining from the military to use in our nursing profession … So now I want to, to gain confidence and learn how to be assertive, they take it and put it into a box. So basically, what they

are doing is that they are preventing us from reaching our full potential.

(FGS2–1:117)

Participants also believed that they were not allowed to make mistakes, and that if they did, they were being demeaned and shouted at by the clinical staff.

… or maybe if you make a mistake, we are still student, we are learning. Maybe if we make a mistake, nè, instead of like having that room for you … like mistakes and everything, nè, because we are always being supervised … we are supervised, you know this one. If you don’t know something, you go and ask. But even that is a challenge. So now, if you make a mistake in the patient like, okay, I was supposed to give you this for that, then they, I don’t

know … Maybe it is because of the rank that we have that makes them to

approach us in that way. (FGS1–4:202)

Now, when you come there as a student and you do some mistakes, it is like you are nothing and you will feel so bad because someone will even be

shouting at you like you are doing nothing. (FGS2–2:55)

In terms of clinical, I would involve my students more in the ward, give them the initiative to do, to make mistakes in the ward, not always be behind them and saying do this, do this, but give them that floor to experience how they

are supposed to experience. (FGS2–5:184,185,186,187,188)

Participants indicated that they were happier to go back to a ward where they were being given positive feedback and acknowledgement from the staff for what they had done.

As a student, I will be happy to go to that unit because I know tomorrow, when I come back from work, at least I will have learnt something or at least the sister could have told me something positive You acknowledge your student. Don’t only focus on you … you took an hour lunch. You will say, ‘Hey, you have been doing this and this’, acknowledging the students. At

least you can help some positive influence in there. (FGS2–6:208,209,210)

Participants observed that nurses were not acknowledged by other members of the multidisciplinary team and that that made them feel inferior.

Being a nurse can be difficult at times because other people in the multidisciplinary team can make you feel little or like you are less experienced, even if you have been in the profession for long, a newcomer intern doctor can pretend as if he he/she can steer the ship in the right direction than you just because you are [a] nurse, and people think anyone

can be a nurse and it does not take anything to be one. (CIN–1:10)

4.2.3.1.2 Patient interaction

One participant shared the experience that she had had while nursing wounded soldiers from the deployment areas. She related her feelings when they had shared their experiences with her, thereby showing trust in her.

… there was an incident within the military where we had our soldiers injured in Central African Republic. So, I was fortunate that I was allocated in Ward 15. So, the ward was cleared. All our patients were sent to another ward. Then those patients they all came to us. So, it was quite a nice experience because I met the big people of the SANDF, the generals and all that. Not anybody can meet the General of the whole SANDF, but I got an opportunity to be at least in the same room as them or being next to them. Also nursing those, those patients and talking to them, share them, trusting you to share their experiences what they went through wherever they were. So it was quite

… I felt like a real soldier at that time, even if I was not in deployment. (FGS1–1:28,29,30,31)

Another participant related how a patient’s gratitude had inspired him to be more committed to the patient and how the patient’s recovery had served to motivate him.

Then it was like each and every day when I came to work, I am glad you are

here. (FGS1–2:44)

I am telling you, when I saw that patient was healed and he was okay …

Always every time when I came to work, I was always in that room or in that patient’s room, and preaching until that patient, one day you will be walking. I believe by the strength of God you will stand up. I am telling you guys, I show him that I care, the patient was up and about. He was active again and he went home healthy. I was motivated. I was like, wow, I like this thing, I love

nursing. (FGS1–2:45,46,47,48)

During the focus-group interviews, lengthy discussions revolved around the attitudes of patients in the military clinical facilities as compared with those in the civilian facilities. Firstly, reference was made to patients who had refused to be treated by students. This circumstance not only denies students opportunities for learning but also makes them scared to enter patients’ rooms, which affects their confidence.

With my experience, once, when nursing this other patient, a VIP patient here in the military institute, xxxx this patient said that she doesn’t really wants to be nursed by a CO. It comes back again with the ranks in the military. She

told me that she would rather be nursed by a Captain than a CO. (FGS1–

3:180)

… because if you are taking care of, let’s say, for instance, a colonel or a major and they know you are a CO because you are wearing your rank, nè?. The same approach applies. When they come to you, you said no, no, use your, like she said … ‘I don’t want to be treated by you, I want to be treated

by someone else’. (FGS1–4:201)

Numerous examples were given of patients making unreasonable demands of nurses, expecting that everything had to be done for them and thinking that they each deserved special treatment. Yet no appreciation had been shown.

Some is like, they are lazy, they just don’t want to help here, especially in the military. They expect you to do everything for them. When you tell them maybe you must lift them, they, they must lift their bodies just to help. They

don’t want to do that. They expect you to do everything since you are a CO.

(FGS2–2:56)

Ja, like, in the military, some patients they don’t appreciate you being there

But here, in the military, it is like they have been … it is like these people they take [the] military or as a private hospital or something whereby just

everything must just be concentrated on them. (FGS2–2:61)

One participant related how a patient had expected to be addressed in her home language. When the student had been unable to understand her, she was accused of being ‘useless’.

Then the patients started using their own home language. That way even though my fellow colleague couldn’t hear what the patient is saying … luckily for me I could hear some certain words what that patient was saying. Then my fellow colleague said, ‘I don’t understand’. Then they asked her, ‘Why are you here in the military whereas you don’t know this language? You must just still resign today because you are useless to us. You can’t even understand

what you are hearing’. (FGS2–6:62,63)

The issue of rank and how patients with higher ranks are treated or expected to be treated also elicited a number of examples from participants. The allocation of higher- ranking patients to private rooms with better furniture, equipment and food was one of example of discriminatory treatment based on rank.

But here, especially when we … they can call from casualty that the Colonel or General, whoever is coming. During handover, they will emphasise again [that in] this room and this room there is [a] Colonel, there is [a] General, whoever, whoever. This room is a private room, [a] VIP [room] for [a]

General, whoever. (FGS1–5:211)

When I was doing my second stage in 2013 and placed xxxx I nursed a patient who was in room 2 (VIP). The first time when I entered the room I thought I was in one of the expensive hotel rooms! The room had a television, radio, nice couch, beautiful, or with a glass and white cups and fresh flowers. The patient was also eating different food from the other

patients, much more appetising! (CIN–4:54)

The following extracts illustrate participants’ experiences involving patients who had expected or demanded preferential treatment on the basis of their rank. In one instance, a patient had demanded to be helped first because he had had a higher rank than the patient with whom he had been sharing a room. In another instance, a General had demanded to be addressed by his rank and had refused to be treated by students. One participant indicated that an attitude of this nature made it difficult for students to perform their duties and that they were wary of entering the rooms of patients with high ranks.

I remember, I was nursing this … there were patient, it was a Private and a Sergeant Major. So, the private called me first and I was attending the

Private. The Sergeant Major called me, ‘CO, CO, please come help me’. I

was like, ‘Sergeant Major, I will, I will attend to you. Let me just finish with the Private here’. He was like, ‘But I am a Sergeant Major here!’ Then I waited, I

[waited] patiently that … done everything with the patient then I go to

Sergeant Major. I am like, ‘Sergeant Major, you must learn to be patient, that is why you are here’. He was like, ‘But CO, you must treat [patients] according to the ranks. You can’t see I am … I am having a higher rank, you

must tend to me first’. (FGS1–2:208)

I was in xxxx, nursing a “patient” whose rank was a General. According to him, he was supposed to be treated like a general not a patient which makes our work so difficult. He demanded that we address him with his rank not patient. He also did not like it when students nursed him as he was too superior to be nursed by people who did not know what they were doing. This made me sad and confused in a way. Because we are supposed to be learning but how do we learn if we being push aside? We were supposed to

be treating a patient not a General. (CIN–6:90)

… if the patient has a higher rank, then they accept to be treated special than the other, the other patients. So, for me to carry out my work is difficult because, when I go into their room, I feel scared to do some of the things

because they always complain. (FGS2–3:9)

One participant had had an experience involving a General who, even as a patient, was still ‘commanding’ the ward.

Once you go there that General is having that mentality of his owning

everyone in the ward even though he is [a] patient and I am [a] nurse.(FGS1–

5:212)

Even patients who were only related to higher-ranking officers had demanded preferential treatment.

Because, for example, we were working in [a] gynaecological clinic and then a General’s wife, even if the person is not [in the] military, just because she is married to a General now, she must be recognised. So, most patients in gynaecological they all come in, they take the file, first come first serve. So, she came in, she is like, ‘Can I see doctor so and so?’ Then we were like, ‘Okay, do you have an appointment?’ That is the question you should ask. You cannot just say okay, ‘He is [in] Room 11. You do have an appointment?’

Then the answer was like, ‘Do you know who I am?’ You see, those things,

now, I am a General’s what, what, wife and whatever. It is like the General’s wife or the General cannot sit in the queue; whenever they come they should

just go in that time. So, it is something that is so difficult to deal with.(FGS1–

1:225)

Participants indicated that they had found it difficult to nurse patients when they were expected to consider the ranks of the patients before they could treat them.

I feel that in the military, as a nursing student or as a nurse, how it has affected my profession is that you have to be a soldier and a nurse at the

same time; especially when we are working in the … like in xxxx. You find

people of higher ranks. There you have to consider their ranks before you can treat them. Let’s say it is [a] General who come in, you have to salute or

acknowledge that person as [a] General, not as [a] patient who … who …

then you have to acknowledge that person as General whatsoever, General whatsoever name. So I think sometimes starting, let’s say, you didn’t even check the name of the patient or maybe you didn’t acknowledge first the rank of that person, when you get there patient ma-ma-ma or patient so-so sorry.

Then that patient get offended that you are not respecting their ranks.(FGS2–

2:5,6,7)

4.2.3.1.3 Learning experiences

The smaller patient population of military clinical facilities results in fewer clinical learning opportunities for students.

I … our … will say that patients, our military patients, they are not that

much as if they are in the public sector. [In the] public sector you nurse a

lot of patients. (FGS1–3:64)

As a result of the smaller patient population students are competing for limited learning opportunities.

Even the students also, you find you are allocated with a, let me just use this,

selfish students. You know what I am saying? Maybe you will find … Like

when they allocate us in the allocation according to where you are going, you are going [to] xxxx, they will just, say maybe ten people are going to xxxx. Then it is postnatal, antenatal and labour. Then they will divide three, three, three and the other ones will be four because we, we are ten. Then you will find some students, they know you haven’t done certain procedures but then just because they want to be there, they want to be done a certain procedure, they don’t care. Even [if] you agree on the first day that we are going to rotate, maybe after two days, three days, you find some other students, what

they are doing is they are telling you, ‘No, we are not going to move. I am

In document The influence of the hidden curriculum on professional socialisation of student nurses in a military nursing context (Page 151-167)