Student Expectations of Nursing Education
- Issues surrounding courses and the provision of nursing education
- Course and teaching
- Practicum experience
- Institutional representations of the course
- Evaluations and Inferences Drawn from the Findings
Issues surrounding courses and the provision of nursing education
It is important to acknowledge that courses have the potential to modify and influence the aspirations and desires of students and this facet merits consideration.
Students reflected a view that suggested a demarcation between academic and practical approaches to nursing. The level to which this was an issue of concern clearly depended on the skill of the teaching staff and the ethos of the different campuses. One participant, Louise, a first year nursing student who had completed HSC the previous year, felt that her course was geared towards those wanted to pursue an academic career, despite the fact that most students did not aspire to academic careers. Louise was concerned at the lack of practical experience in the course, and she highlighted this concern by noting that all assessment had consisted of written essays, and that no assessment had been made of how well practical tasks could be performed. Consequently, the majority of student effort is devoted to academic rather than practical tasks in order to pass the course. Students considered that the course was highly geared towards preparing nurses as researchers yet none of the students anticipated continuing to use the research skills that were taught.
At university, while there was a perceived emphasis on the history of the profession in the course, there was a distinct difference in how the profession was portrayed by staff. Some staff emphasised the routine, unpleasant and mundane aspects of the job, followed by the message that you would have to be nursing for the love of the job rather than the money. Nursing, these teachers claimed, occupied the lowest position in the health care hierarchy, and emphasised that nurses were poorly regarded in the community, and that they would always 'be under fire'. Paula reported that many students, she included left these classes feeling disillusioned, as though every reason that the students had chosen to go into nursing had been under-mined. However, other teaching staff commended students on electing to pursue a noble, important and worthy profession. Steve, a 52 year old former ambulance driver, added that he felt many of the university staff had left nursing when they became burnt out, but had carried that attitude into their teaching practice.
Concern was expressed that university based teaching equates to what is basically self-learning. Students are provided with information in a lecture, told once 'short hand way'. The onus is then on the student to make sense of the material if they can. This contributed to the students' lack of confidence in the course to adequately prepare them for the demands of their profession.
A point of some concern to the students was a perceived disjuncture between the expectations and demands of practicing nurses and teaching staff. Additionally, there was often confusion between what academics say and what practitioners on the wards say is relevant.
Students felt that too little time was spent demonstrating techniques, and that too much reliance was placed on students learning a procedure from one viewing. A number of students lamented that there was little or no real opportunity to learn basic skills while at university. Some complained that university practices such as three-hour tutorials were mostly just another lecture, leaving little time to practice skills.
Students felt that they did too little practical work during their programs. This concern was consistent across the groups, all of whom nurtured visions of working as ward nurses. They wondered how activities such as learning to critically analyse journal articles would develop their nursing skills, and often expressed uncertainty over the relevance of specialist theoretical knowledge, particularly in relation to its applicability to 'real life situations'.
They saw problems with the way clinical practicums were arranged. Some of the difficulties cited included a considerable amount of travel from the areas in which they reside, as well as economic constraints encountered during practicums. For example, those who had part time work jobs had to take leave and therefore had no pay during their clinical placement, a situation that presented particular difficulties for single parents in the groups.
Among students there was the feeling that if more practicum experience was provided in first year, students would have a more realistic expectation of what nursing work was like. As Joe put it, 'get rid of the TV stereotypes' and see that the reality was different.
Institutional representations of the course
Institutional representations of both the courses and the nursing profession varied considerably among the various institutions. While these representations were not cited by students as having a direct impact on either their expectations of nursing training or their professional and lifestyle aspirations, they were seen as having an effect in terms of the way in which courses are perceived, structured, and delivered.
Evaluations and inferences drawn from the findings
The construction of nursing identities
There is a general consensus in contemporary discourses concerned with identities and categories of identity, that individual identities are socially constructed, and vary across contexts and time. Notions of individual and collective identities within the domains of the social sciences, humanities and critical theory are underpinned and informed by various conceptualisations of the 'self' or the 'subject' which is constituted by and within social and discursive practices determined largely by historical and cultural specificities, and by Foucaultian notions of subjectivity (Mansfield 2000; Youdell 2000)
There is particular relevance of these debates to a consideration of the aspirations and expectations of students of nursing, as students' conceptualisations of themselves as individuals, as students, and as nursing professionals are conceptualisations in process. These perceptions of individual and social identities, and categories of identity, may be helpfully understood as social constructions which occur as a result of the particular historical and discursive locations of individual subjects, and which are "fluid, relational, hybrid" (Weeks 1999, p.17), contingent upon the range of experiences encountered and the relations of power within which individuals are posited.
The individual construction of nursing identities is an important aspect of the educative process for students of nursing. While students bring to this process a collection of narratives about themselves as individuals and members of family and social groups, a significant proportion of their identities as nurses is developed during their professional training, and is necessarily impacted upon by their experiences as students situated within tertiary institutions, and as emerging professional clinical practitioners. In this way, the educational and vocational experience of acquiring nursing skills functions to underscore the notion that social practices and institutions which occur within public spheres "are the arenas for the formation and enactment of social identities" (Fraser 1994, p. 85). Nursing students must negotiate an array of textual and narrative representations, as well as lived experiences, in order to integrate those experiences within their own personal narratives, and to then posit themselves within a category of identity such as nursing student or nursing practitioner.
As the data from this research shows, nursing students' aspirations and expectations are often either generated from, or altered as a result of their conceptualisations of their identities as students and as nurses. These conceptualisations are continually modified as they progress through various stages of the course, and impact on students' constructions of their own identities, as well as their constructions of collectively understood categories of identity. For example, some participants noted having been anxious about their capacity to succeed within the socially constructed category of student. In particular, those who had achieved poorly at school level, or who had not matriculated, had questioned whether they possessed the particular qualities and capabilities they had attributed to the student category of identity. Their acceptance into the nursing course, and their experiences of achieving satisfactorily at tertiary level had proven to be an important aspect of their own identity construction. They were able to see themselves as legitimate members of a category of identity to which they ascribed particular significance, and noted the impact on their intentions to persist with the course and pursue a nursing career.
Additionally, there was a consensus amongst the participants in the study that their aspirations concerning areas of specialist nursing were directly influenced by their experiences during practical training. Indeed, students often qualified their responses to questions concerning their career goals by reference to their most recent 'prac' experience. Typically, students who had recently completed a 'prac' in paediatrics expressed an intention to pursue a specialism in paediatrics, and so on. Also, one student who envisaged herself working as a theatre nurse discovered that this would be inappropriate because she was claustrophobic. First-hand experience appeared to be a crucial factor in students' capacities to conceptualise themselves within an increasingly diverse array of contexts. Some reported that while they had initially been apprehensive about working within a particular area of nursing, such as mental health nursing, once they had experienced it first-hand, they were prepared to alter their initial conceptualisations in order to accommodate a new, previously unexpected set of possibilities.
Institutional identity
The degree to which the institutional representations and discursive practices of universities and hospitals function in the construction of students' social identities, and which subsequently impact on their aspirations and expectations of nursing, may be helpfully explored according to models of critical discourse analysis. For example, Fairclough's (1992) model of critical analysis of text, discursive practice, and social practice, provides a useful framework for considering the construction and function of institutional identities via an array of texts, institutionally specific ideologies and practices, as well as various conceptualisations of nursing practice which predominate amongst nursing staff involved in the practical supervision of nursing students. Explored in this way, educational institutions such as universities, and social institutions such as hospitals, may be seen as discursive participants in nursing education, which construct identities for themselves, as institutions, and in that process, play an important role in informing the constructed identities of nursing students.
While a detailed analysis of institutional identities in relation to the construction of nursing identities is beyond the scope of this paper, this section will consider two aspects of institutional identities which are of particular importance to a discussion of nursing students' aspirations and expectations. Firstly, consideration will be given to the construction of institutional identities through particular texts and discursive practices which represent nursing practice to students in particular ways, and secondly, the role of institutions in the construction of official knowledges and legitimised forms of participation will be discussed.
In much the same way as individual identities are constructed in process, through a combination of self-perception, narratives, group membership identification, relationships and social experiences, the development of a recognisable social structure which can convince employees, prospective clients, registering bodies, governments and markets of its capacity to adequately deliver a particular product or service draws on an array of cultural representations, social expectations, organisational activities, workplace cultures, and professional requirements, as well as political and economic conditions and imperatives, to construct institutional identities which are seen as representative of the actual institution. The narratives and rhetoric thus employed "involve[s] the construction of the organization as a purposive entity with a trajectory towards a desired future" (Hopfl 1999, p.130, emphasis added).
As the data generated from this research demonstrates, the representations of nursing courses and nursing practice varied considerably between tertiary institutions, and again between the universities and the hospitals in which practical training was conducted. As the universities involved in the study variously presented their own nursing programs, and the nursing profession, according to models categorised here as entrepreneurial, vocational, professional, and obligatory, so students' comments concerning their own aspirations and expectations reflected to an extent the approach taken by their particular university. For example, universities which constructed an entrepreneurial representation of the nursing profession, emphasising benefits of choosing a nursing career such as travel and the possibility of using nursing training in a variety of contexts, took an entrepreneurial approach to representing themselves as institutional identities, most notably reflected in the availability and accessibility of high quality, professionally produced website and printed materials. Correspondingly, students from those universities had incorporated entrepreneurial constructions of nursing practice into their own aspirations and expectations, and indicated a high degree of interest in combining nursing with travel, and in taking advantage of the professional mobility they perceived nursing to offer. Similarly, the vocational representations of the nursing program and nursing practices of one university were reflected in the vocational aspirations and expectations of the students enrolled in training at that particular institution. Although there were exceptions, the students whose institutional experience of nursing education had a substantial focus on preparing students for traditional nursing in hospitals predominantly considered those models fundamental to their aspirations and expectations of nursing practice. While it may be argued that institutions which represent particular institutional characteristics in relation to their provision of nursing training according to a particular model will be likely to attract students whose own aspirations and expectations are already similarly inclined, the power of images to "create a version of reality" (Pearce 1999, p.81) should not be overlooked. Indeed, given that "[i]mages are...constructions designed to communicate, and consolidate, ideological 'truths'" (Davidson, cited in Pearce 1999, p.81), their inscription into official discourses of nursing education and professional practice gives them a particular legitimacy in the construction of individual students' nursing identities.
Similarly, students from one university whose institutional identity was represented, through textual promotional materials, structural organisation, and course content as being fundamentally concerned with equipping nursing students with an array of professional competencies, demonstrated alignment to notions of nursing in professional terms. The integration of professional representation of the university's institutional identity, combined with a demonstration of professional collaboration in producing a course with a high degree of consistency at each level in the course structure, appears to have contributed to an integration of professionalism into students' constructs of nursing identities. Conversely, those universities whose representations of and approaches to nursing education have been categorised as obligatory, were more likely than others to have students whose conceptualisations of themselves as nursing students and aspiring practitioners were fragmented and inconsistent. Students who considered their tertiary experience to be characterised by conflicting representations of nursing practice, ranging from 'worthwhile and honourable' at one end of the spectrum, to 'undervalued and thankless' at the other, coupled with what they saw as a high degree of administrative inefficiency and a low level of personal interest shown in their progress through the course, correspondingly reported a considerable degree of ongoing difficulty in reconciling their own aspirations and expectations of nursing to the anomalies with which they were continually confronted at an institutional level.
Similarly, the majority of groups who participated in this study made reference to a substantial disjuncture between the institutional and personal constructions of nursing education and professional practice, and those of nursing staff in hospitals who had been trained under the previous hospital based system, and under whose instruction the clinical aspects of their training was conducted. While at one level this disjuncture may be seen as a temporary, transitional effect brought about by changes from hospital based to university based training, at another level it warrants interrogation as representations of nursing which have a constitutive effect in the ways in which nursing students are both institutionally constructed, and the ways in which they construct their own identities as nurses. Organisational culture, defined by Duncan as "the behavioural norms and psychological attitudes which are consciously or unconsciously enacted by organisational members as they seek to understand their collective structure and identity through formal and informal events such as meetings, organisational charts, and written and unwritten rules" (Duncan 1995, p. 164) is a powerful influence on the ways in which aspiring nurses conceptualise themselves as both students of nursing and as nursing professionals.
These issues raise questions concerning the role of institutions in the construction of official knowledges and legitimised forms of participation, which are fundamental to the constitution of students' socially constructed identities in relation to nursing. Universities and hospitals are the key sites for the construction of official knowledges concerned with nursing practice, together functioning as a discursive formation, a Foucaultian term which "refers to the systematic operation of several discourses or statements constituting a 'body of knowledge', which work together to construct a specific object/topic of analysis in a particular way, and to limit the other ways in which that object/topic may be constituted" (Barker and Galasinski 2001, p. 191). Through the constitution and dissemination of the 'body of knowledge' which nursing students must necessarily negotiate and incorporate into their own nursing identities in order to achieve their personal and professional goals of becoming registered nurses, universities and hospitals function as institutions which "construct their ideological and discoursal subjects; they construct them in the sense that they impose ideological and discoursal constraints upon them as a condition for qualifying them to act as subjects" (Fairclough 1995, p.39). For students of nursing, then, the process of acquiring the official knowledges, which qualify them as discursive participants within the nursing profession, operates to align them as social subjects to the institutions within which they are positive, while simultaneously having a constitutive function in relation to their nursing identities.
Attracting new nurses
Identity construction and the dissemination of this identity are pivotal to the enterprise of attracting students to courses of study, nursing included. It would seem essential that universities clarify what they understand nursing to be before they advertise the course. In some institutions, typically those with poor institutional identities, there was an overt reliance on popularly constructed images of nursing and universities, because it seemed that no effort had been made to produce material that either promoted the course or the institution.
Attracting students relies on a combination of things: making information available to those already intent on doing a particular course, presenting the course as a potential option to those who are interested but undecided, highlighting the advantages of the course to those who haven't considered tertiary study and encouraging the course to be considered as an option for those considering a number of possibilities. These elements will not all be best presented in print materials. A number of students indicated that they had enrolled because they had relatives who were or had been nurses while others said they that observing nursing persuaded them. If this latter point is so then universities would do well to encourage schools to create work experience opportunities in hospitals for year ten students.
Retaining students
The strategy for retaining students is not inconsistent with that suggested for attracting students. Teaching materials should reflect … have a fully integrated program, where lecturers all knew what each other were doing and endeavoured to integrate their teaching. Consequently, students received consistent course content information and were presented with cohesive images of nursing. … The issue of difference between hospital trained and university-educated staff could also be addressed using this approach. Critical engagement with clinical practice experiences would allow 'prac' to be more securely embedded with the program and would lessen the sense of divide between university staff and others.
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