Through discussing their clinical placement experiences, a group of second-year nursing students at a New Zealand university concluded their self-esteem was connected to their ability to self-advocate, which helped create a positive clinical experience.
This article explores some of the barriers which inhibit nursing students’ self-advocacy and makes recommendations to support them to successfully advocate for themselves while on clinical placement.
What is self-advocacy?
Nurses need to be able to advocate for their patients; however, this begins with developing the capability to speak up confidently and advocate for oneself.1 Self-advocacy for student nurses is also about being able to communicate learning goals and actively work towards achieving them.2 A student nurse who self-advocates understands their rights, communicates clearly and practises leadership skills.1
Clinical placements can be challenging and stressful for student nurses. Cultivating the skill of self-advocacy helps them to succeed in their learning and ensures quality education.3
Clinical preceptors may be unsure of each nursing student’s education level or capabilities. They may have low expectations because they see the nursing students as having less experience, or they may have high expectations that place nursing students in situations where they feel out of their depth and unsafe.4
The nursing student, therefore, has a responsibility to clarify with the health-care team their expectations of the student’s knowledge and skills.2 Advocating for themselves enables the student nurse to persist and advance in their academic performance, despite any challenges that arise.
Nursing education should support the development of student self-esteem to prepare them to transition into registered nurses (RNs).5 It is important that nursing students understand that having confidence and self-esteem increases their ability to self-advocate.
Often nursing students can feel intimidated by their perception of the hierarchy in the health-care team, which prevents them from having the courage to self-advocate.6 They are silenced by their desire to fit in and by the anxiety of potentially receiving negative repercussions or being ignored.
Often nursing students can feel intimidated by their perception of the hierarchy in the health-care team, which prevents them from having the courage to self-advocate.
Key barriers to nursing student self-esteem and self-advocacy include poor communication between clinical preceptors and students, lack of confidence and inadequate supervision, which in turn have a negative effect on their clinical performance.7
Clinical placement should be a safe setting to ask questions and put theoretical skills into practice. However a common factor contributing to low confidence in nursing students during placements is bullying and intimidation from RNs.8,9
One nursing student related her experience with intimidating preceptors, saying their attitudes resulted in her being too afraid to speak up. She described multiple encounters in which her preceptor expressed annoyance at her for not knowing certain medications, even though it was only her second week on placement.
This attitude resulted in the student having anxiety and low confidence before shifts as she knew she would be paired with the same preceptor. This highlights the importance of a good preceptor-student relationship to encourage the student’s self-esteem in the clinical setting.
Nurses need to be able to collaborate with colleagues and the wider health-care team to facilitate and coordinate patient care.10 This requires a good level of self-esteem and the ability to self-advocate.
Clinical placement should be a safe setting to ask questions and put theoretical skills into practice.
One student nurse discussed her struggles with self-esteem and self-advocacy when interacting with the multidisciplinary health-care team. The student described herself as naturally introverted and said she felt like an inconvenience when having to voice concerns to team members because she lacked experience and knowledge.
To gain confidence as a student nurse, it is important to gradually take on patient loads independently.11 A student nurse talked about how her lack of confidence resulted in her being overly dependent on her preceptors when providing patient care. She held back from making care decisions and relied on her preceptors to assess and plan patient care.
Another student talked about taking on far too large a patient load for their relative skills, due to significant staff shortages. They felt too afraid to speak up and ask for help. These are examples of how low self-esteem prevents student nurses from advocating for themselves and their patients, which can result in poor patient outcomes.12
For nursing students, being able to make decisions is an important aspect of developing a sense of empowerment.13 This can be difficult when nursing students work under the delegation of RNs who may not know how to properly support their students.
It is therefore important that RNs are given preceptor training in how to effectively support nursing students during their clinical placements. This should include treating students with dignity, expressing gratitude for their contributions, helping them make clinical decisions, and helping them make meaningful contributions to nursing care.13 RN preceptors who demonstrate empowering behaviour to nursing students help to increase their confidence and self-efficacy.13
Having enthusiasm and confidence paves the way for individuals to make decisions and act on their own behalf.14 Strategies to improve self-confidence include setting goals and celebrating achievements as each milestone develops their knowledge and capabilities.
One nursing student felt that actively showing enthusiasm and confidence resulted in their preceptors ensuring they were involved in new procedures that were rare to the ward. Nursing shifts are often busy and workloads heavy, so preceptors may at times forget they have a nursing student. Therefore, the nursing student must actively communicate their interest and seek out learning opportunities. The student credited their ability to practise independently under supervision to their ability to communicate their nursing skills and learning goals to their preceptor.
It is also important for nursing students to identify their competence in the clinical setting. Preceptors may find it difficult to recognise a lack of knowledge or confidence,15 therefore students need to inform them of their current abilities.
One student reported that they did not face unnecessary stress when they acknowledged their abilities with their preceptors early on, which meant they were not placed in situations where they felt unsafe. They felt that their preceptor developed trust in their capabilities and ability to advocate for themselves, which resulted in them being given a patient load under supervision.
Another student talked about taking on far too large a patient load for their relative skills, due to significant staff shortages.
When a nursing student self-identifies their clinical skills, they become more confident within their practice and progress. If students have set objectives and expectations for their placement, their preceptor will have more direction on how to support them and meet their goals.16
Training in team communication in a wide range of clinical settings helps nursing students improve their confidence and self-advocacy skills.6 As well as being able to communicate with their preceptors, students should be supported to communicate with fellow students.
Collaboration with peers leads to students feeling safer and more supported in practice, resulting in an overall increase in self-confidence.17 Sharing experiences and knowledge with peers helps build confidence in clinical practice, develops knowledge and skills, and decreases stress and anxiety.18,19 Therefore, supporting peer communication and collaboration during clinical placements helps to develop student confidence and ability to self-advocate.
Self-advocacy is an attribute that greatly benefits nursing students during clinical placements and results in improved patient outcomes. Organisations should consider the above recommendations to support clinical preceptors and nursing students, thereby improving the clinical placement experience and developing confident skilled nurses.
Maddi Downer, Joan Waipouri, Gabie Roquid, Steven Li, Tamar Nonoa, Rachael Work and Katie Ferguson are second-year nursing students. Willoughby Moloney, RN, PhD, is a lecturer in the School of Nursing, University of Auckland.
This article was reviewed by Sally Dobbs, RN, EdD, MSc, MAEd, who is the head of faculty at SIT2LRN at the Southern Institute of Technology, Invercargill.
- Doherty, C., Landry, H., Pate, B., & Reid, H. (2016). Impact of communication competency training on nursing students’ self-advocacy skills. Nurse Educator, 41(5), 252-255. https://doi.org/10.1097/nne.0000000000000274
- Daly-Cano, M. R., Vaccaro, A., & Newman, B. M. (2015). College student narratives about learning and using self-advocacy skills. Journal of Postsecondary Education and Disability, 28(2), 213-277. https://files.eric.ed.gov/fulltext/EJ1074673.pdf
- Cadigan, K. (2017). Supporting the struggling nursing student in clinical practice. University of Canterbury. http://dx.doi.org/10.26021/9690
- Minton, C., & Birks, M. (2019). “You can’t escape it”: Bullying experiences of New Zealand nursing students on clinical placement. Nurse Education Today, 77, 12-17. https://doi.org/10.1016/j.nedt.2019.03.002
- Zamanzadeh, V., Valizadeh, L., Badri Gargari, R., Ghahramanian, A., Jabbarzadeh Tabriz, F., & Crowley, M. (2016). Nursing students’ understanding of the concept of self-esteem: A qualitative study. Journal of Caring Sciences, 5(1), 33-41.
- Jones, A., Blake, J., Adams, M., Kelly, D., Mannion, R., & Maben, J. (2021). Interventions promoting employee “speaking-up” within healthcare workplaces: A systematic narrative review of the international literature. Health Policy, 125(3), 375-384. https://doi.org/10.1016/j.healthpol.2020.12.016
- Gemuhay, H. M., Kalolo, A., Mirisho, R., Chipwaza, B., & Nyangena, E. (2019). Factors Affecting Performance in Clinical Practice among Preservice Diploma Nursing Students in Northern Tanzania. Nursing Research and Practice, 2019, 1-9. https://doi.org/10.1155/2019/3453085
- Amoo, S. A., Menlah, A., Garti, I., & Appiah, E. O. (2021). Bullying in the clinical setting: Lived experiences of nursing students in the central region of Ghana. PLOS ONE, 16(9), e0257620. https://doi.org/10.1371/journal.pone.0257620
- Porter, J., Morphet, J., Missen, K., & Raymond, A. (2013). Preparation for high-acuity clinical placement: Confidence levels of final-year nursing students. Advances in Medical Education and Practice, 4, 83-89. https://doi.org/10.2147/amep.s42157
- Nursing Council of New Zealand. (2016). Competencies for registered nurses.
- Liljedahl, M., Björck, E., Kalén, S., Ponzer, S., & Bolander Laksov, K. (2016). To belong or not to belong: Nursing students’ interactions with clinical learning environments – an observational study. BMC Medical Education, 16(1).
- Nibbelink, C. W., & Brewer, B. B. (2018). Decision-making in nursing practice: An integrative literature review. Journal of Clinical Nursing, 27(5-6), 917-928. https://doi.org/10.1111/jocn.14151
- Perry, C., Henderson, A., & Grealish, L. (2018). The behaviours of nurses that increase student accountability for learning in clinical practice: An integrative review. Nurse Education Today, 65, 177-186. https://doi.org/10.1016/j.nedt.2018.02.029
- Singer, B. D., & Mogensen, J. (2021). Getting students to self-advocacy — Step by step. Ashawire.
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Brown, P., Jones, A., & Davies, J. (2020). Shall I tell my mentor? Exploring the mentor‐student relationship and its impact on students’ raising concerns on clinical placement. Journal of Clinical Nursing, 29(17-18), 3298-3310. https://doi.org/10.1111/jocn.15356
- Adel, E., Löfmark, A., Pålsson, Y., Mårtensson, G., Engström, M., & Lindberg, M. (2021). Health-promoting and -impeding aspects of using peer-learning during clinical practice education: A qualitative study. Nurse Education in Practice, 55, 103-169. https://doi.org/10.1016/j.nepr.2021.103169
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