Why Students Become More Fearful Over Time

I came across research recently that stopped me in my tracks.

Altmiller's national study of 268 nursing students across 46 states found something deeply troubling: students become MORE fearful of reporting safety events as they progress through their programs. End-of-program students are significantly less willing to report errors than students just beginning their clinical experiences.

Let that sink in. The longer students are in nursing programs, the more afraid they become.

This isn't what we intended. We don't set out to teach fear. But somewhere between orientation and graduation, students are learning a lesson we never meant to teach: honesty is dangerous.

What Students Are Actually Learning?

This pattern isn’t primarily about students lacking reflection or accountability skills, though those matter and need development.  It’s about students learning that using those skills honestly is dangerous. 

Students are observing. They're listening. They hear what happened to the student who admitted making a medication error. They watch how faculty respond when someone asks for help. They notice which mistakes lead to "learning opportunities" and which ones lead to remediation plans, extra paperwork, or being labeled as "unsafe."

Whether the stories they hear are entirely accurate or not doesn't matter. Students form opinions based on what they observe. And they reach a logical, rational conclusion: the system can't be trusted. Being honest doesn't lead to learning and growth. It leads to consequences, scrutiny, and risk.

So, they adapt. They enter survival mode. They keep their heads down, do exactly what they're told (robots), and protect themselves until they can pass and move on to the next semester, or finally graduate.

Their self-orientation becomes high out of sheer self-preservation.

The Culture We're Creating

This is what concerns me most: we're not creating accountable professionals. We're creating people who've learned to hide, to stay silent, to protect themselves above all else.

And then we wonder why new graduates struggle to report near-misses. Why they don't speak up when they see something concerning. Why they seem to lack that internal accountability we expected them to develop.

They developed exactly what we taught them, just not through our curriculum or our policies. They learned it through experience, through observation, through the culture we created whether we meant to or not.

Lucian Leape, a pioneer in patient safety research, stated it plainly in 1997: "The single greatest impediment to error prevention is that we punish people for making mistakes." Nearly three decades later, we're still proving him right, and now we're teaching the next generation to internalize that same fear.

David Marx, in his foundational work on just culture, puts it plainly: "There is nothing wrong with holding a practitioner accountable—even with formal consequences—as long as there is a pathway to restoration." But he warns: "An organization gains nothing from a climate in which practitioners are constantly fearful and insecure in their relationship to you. That surely is a culture without trust, and such a culture could never be a just or safe culture."

We've created exactly what Marx warned against. Students aren't learning accountability. They're learning fear.

The Knowing-Doing Gap from the Student Perspective

Here's where it gets complicated: students KNOW they're supposed to be honest, transparent, and accountable. They hear it in orientation. It's in our program handbooks. We tell them constantly about professional integrity and the importance of reporting errors.

But knowing what you're supposed to do and actually doing it are two different things—especially when doing it feels unsafe.

This is the knowing-doing gap from the student side. Not because students don't understand the concept of accountability. But because they've learned that practicing accountability in our current systems is dangerous.

We can't fix this by telling students to "speak up" or "be more honest" or "trust the process, we’re here to help," not when the process hasn't proven itself trustworthy.

What Would Have to Change

If we're serious about developing accountable professionals, we need to acknowledge some hard truths:

First: Policies aren't enough. Barnsteiner and Disch's research found that even when nursing programs have just culture policies, many don't follow them. Students notice that gap between what we say and what we do.

Second: Just culture isn't optional. It's not a "nice to have" or something we implement when it's convenient. If students are going to practice honest self-assessment and reporting, they need to trust that errors will be met with fairness; that human error will be treated differently than reckless behavior, that there's truly a pathway to restoration.

Third: Faculty self-orientation matters. When faculty responses to student errors are driven by worry about program reputation, fear of accreditation consequences, or concern about looking like inadequate teachers, students’ sense that self-protection. And they learn to mirror it.

We can't expect students to have low self-orientation, to be honest and vulnerable about their mistakes, when we haven't modeled it ourselves.

Why This Matters Now

While more research is needed to understand the full scope of this issue, the pattern Altmiller identified—corroborated by Barnsteiner and Disch's finding that policies often aren't followed—suggests we're graduating nurses who learned that the safest strategy is to stay quiet, to hide mistakes, to protect themselves.

This isn't just a nursing education problem. It's a patient safety problem. A workforce problem. A professional culture problem.

And it won't change until we're willing to look honestly at the systems and relationships we've created—and acknowledge that we’re possibly teaching students lessons we never intended.

What I'm Wrestling With

I'm still developing my framework around this. I don't have all the answers. But I'm increasingly convinced that we need more than policies and more than training. We need:

• Systems that are genuinely restorative when appropriate (Just Culture)

• Faculty who can examine their own self-orientation and create trustworthy relationships (Trust Equation)

• Students who have the skills to engage in honest self-assessment when it's safe to do so (Metacognition)

All three. Not one or two. All three together.

But if I'm honest? We have to start with trust. Because no amount of skill-building will matter if students don't believe honesty is safe.

Your Experience

I'm curious about what you're seeing:

Have you noticed students becoming more guarded or fearful as they progress through your program?

What do you think students are learning about honesty and accountability in clinical settings?

If you could change one thing to make your program feel more trustworthy to students, what would it be?

I'm genuinely asking. Drop your thoughts in the comments—I'm learning as I develop this framework, and your experiences matter.

About This Series:
This article is part of an ongoing exploration of integrating Just Culture, trust-building, and accountability in nursing education. You can learn more about The Professional Culture Framework for Nursing Education at: www.theprofessionalcultureframeworkfornursingeducation.com

© 2026 Melinda R. Murray, MSN-Ed, RN

References:

Altmiller, G. (2022). National study of quality, safety, and just culture in pre-licensure nursing education. [Presentation of NLN-funded research]

Barnsteiner, J., & Disch, J. (2017). Creating a fair and just culture in schools of nursing. American Journal of Nursing, 117(11), 42-48.

Leape, L. L. (1997). Testimony before Congress on Health Care Quality Improvement.

Marx, D. (2001). Patient safety and the "just culture": A primer for health care executives. Columbia University.