the structure of stress in nursing education

8/13/2019 The Structure of Stress in Nursing Education

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The Structure of Stress inThe Structure of Stress in

Nursing EducationNursing Education

A TheoreticalA Theoretical--Empirical AnalysisEmpirical Analysis

C. E. BettsC. E. Betts

McMaster UniversityMcMaster UniversityNERU, Dec. 8, 2008NERU, Dec. 8, 2008


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Professional socializationProfessional socialization

Student & graduate nurses learn to think & actStudent & graduate nurses learn to think & actin ways defined for them by the traditionallyin ways defined for them by the traditionally

dominant groups within the health system &dominant groups within the health system &

which they accept as natural, commonwhich they accept as natural, common--sensesense

views of social reality.views of social reality.

Nursing education does not simply 'processNursing education does not simply 'processstudents' or 'process knowledge'; it helps createstudents' or 'process knowledge'; it helps create

& legitimize forms of consciousness which& legitimize forms of consciousness which

reinforce existing hegemonic structures.reinforce existing hegemonic structures.(Clare, 1993, p. 1034)(Clare, 1993, p. 1034)


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Professional socialization is challenged by:Professional socialization is challenged by:

incongruities between education and industryincongruities between education and industry

difficulties in formalizing appropriatedifficulties in formalizing appropriate

administrative and functional support for theadministrative and functional support for the

NG,NG,

a growing expression by nurses ofa growing expression by nurses of

powerlessness within the health care system.powerlessness within the health care system.((BoychukBoychukDuchscherDuchscher&& CowinCowin, 2006, p. 1034), 2006, p. 1034)


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Accountability of Education & Practice WorldAccountability of Education & Practice World

must acknowledge, understand, and workmust acknowledge, understand, and workto resolve the oppressive socioto resolve the oppressive socio--politicalpolitical

context of the hospital environmentcontext of the hospital environment

if we expect to replenish and retain aif we expect to replenish and retain a

motivated and energized nursing workforce.motivated and energized nursing workforce.

((BoychukBoychukDuchscherDuchscher&& CowinCowin, 2006, p. 1034), 2006, p. 1034)


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The Crisis of Nursing??The Crisis of Nursing??There is mounting evidence that the perception ofThere is mounting evidence that the perception of

nursing as a challenging, satisfying, & fulfillingnursing as a challenging, satisfying, & fulfillingvocation by societys youth is waning.vocation by societys youth is waning.((BoychukBoychuk--DuchscherDuchscher&& CowinCowin, 2006, p. 152), 2006, p. 152)

Challenges are:Challenges are:

ShortageShortage

Stress/Burnout/Injury RateStress/Burnout/Injury Rate

Overworked/UnderpaidOverworked/Underpaid

Horizontal Violence/HierarchicalHorizontal Violence/Hierarchical RankismRankism

Devalued/Oppressed/SubjugatedDevalued/Oppressed/Subjugated


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Resolution: Shift toResolution: Shift to

Emancipatory FoundationsEmancipatory Foundations

[Emancipatory] pedagogy takes the problems[Emancipatory] pedagogy takes the problems

& needs of students themselves as its starting& needs of students themselves as its starting

pointpoint

a pedagogy based on student experiencea pedagogy based on student experience

encourages us to analyze the dominate forms ofencourages us to analyze the dominate forms of

knowledge that shape student experiencesknowledge that shape student experiences

Any emancipatory curriculum must emphasizeAny emancipatory curriculum must emphasize

student experience, which is intimately related tostudent experience, which is intimately related to

identity formation. (McLaren, 2002, p. 226)identity formation. (McLaren, 2002, p. 226)


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Literature on Distress in NursingLiterature on Distress in NursingEducationEducation

The level of distress, disengagement, apathy & atThe level of distress, disengagement, apathy & attimes perhaps even desperation, in nursing students,times perhaps even desperation, in nursing students,is becoming critical (Gibbons,is becoming critical (Gibbons, DempsterDempster&& MoutrayMoutray,,2008; Hall, 2004). Moreover, there are powerful2008; Hall, 2004). Moreover, there are powerfulstructural aspects to this phenomenon.structural aspects to this phenomenon.

Preparing to become a nurse is associated withPreparing to become a nurse is associated withsignificant emotional distress and may carry a risk tosignificant emotional distress and may carry a risk to

the affective wellthe affective well--being of the student. (Jones &being of the student. (Jones &Johnson, 1997, p. 481)Johnson, 1997, p. 481)


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Literature on Distress in NursingLiterature on Distress in NursingEducationEducation

By desperation, I am referring to the conditionBy desperation, I am referring to the conditionof being without hope, feeling less than a fullof being without hope, feeling less than a fullperson, and seeing few options.person, and seeing few options.

Such desperation may be fostered, at least inSuch desperation may be fostered, at least in

part, by conditions of educational pressures. Ipart, by conditions of educational pressures. Irefer to students feeling isolated, misunderstood,refer to students feeling isolated, misunderstood,and dismissed.and dismissed.

I also refer to faculty feeling overburdened withI also refer to faculty feeling overburdened with

work and academic expectations associated withwork and academic expectations associated withfulfillment of the faculty role and steepfulfillment of the faculty role and steepexpectations for promotion and tenure. (Hall,expectations for promotion and tenure. (Hall,2004, p. 147)2004, p. 147)


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Is There a Structure to Stress??Is There a Structure to Stress??

The relative lack of organizational level programmesThe relative lack of organizational level programmesto reduce workto reduce work--related distress, and the scarcity ofrelated distress, and the scarcity ofinterventions targeting aspects of the work environmentinterventions targeting aspects of the work environment

likely to contribute to such outcomes may havelikely to contribute to such outcomes may havecontributed to continuing high levels of distress in trainedcontributed to continuing high levels of distress in trainedand student nurses.and student nurses.

Recommendations regarding the future design, provisionRecommendations regarding the future design, provision

and evaluation of such workand evaluation of such work--site interventions includesite interventions includethe further clarif ication of the structure of perceivedthe further clarif ication of the structure of perceivedstressorsstressors , and development of causal models of the, and development of causal models of thestress process to identify the job characteristics `causing'stress process to identify the job characteristics `causing'

workwork--related distress. (Jones & Johnson, 2000, p. 66)related distress. (Jones & Johnson, 2000, p. 66) What about organizational (structural/institutional) stressWhat about organizational (structural/institutional) stress

and distress in school??????and distress in school??????


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Job DemandsJob Demands--ControlControl--SupportSupport

ModelModel

states that psychological strain results notstates that psychological strain results not

from a single aspect of the workfrom a single aspect of the work

environment, but from:environment, but from:

the joint effects of the demands of a workthe joint effects of the demands of a worksituation, &situation, &

the range of decisionthe range of decision--making freedommaking freedom

(discretion) available to the worker facing(discretion) available to the worker facingthose demands.those demands.

((KarasekKarasek, 1979, p. 287), 1979, p. 287)


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Application to University StudentsApplication to University Students

Results showed high levels ofResults showed high levels of

psychological stress & low levels ofpsychological stress & low levels ofsatisfaction, are both linked to highsatisfaction, are both linked to highdemands combined with low control.demands combined with low control.

(Cotton,(Cotton, DollardDollard & de& de JongeJonge, 2002 p. 147), 2002 p. 147)

Levels of satisfaction have a direct impactLevels of satisfaction have a direct impact

on student performance & mediate theon student performance & mediate therelationship between academic workrelationship between academic workcontrol & performance. (control & performance. (ChambelChambel &&

CurralCurral, 2005, p. 135), 2005, p. 135)


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Is the introduction of a studentIs the introduction of a student--centred, problemcentred, problem--basedbased

curriculum associated with improvements in studentcurriculum associated with improvements in student

nurse wellnurse well --being and performance?being and performance? (Jones & Johnston, 2006)(Jones & Johnston, 2006)

[PBL students] reported less distress in their[PBL students] reported less distress in theirfirst year of the course, they scored less well onfirst year of the course, they scored less well oncomparable essay assignments and had greatercomparable essay assignments and had greater

sickness absence totals (p. 941)sickness absence totals (p. 941) increased levels of support [from smallincreased levels of support [from small

groups] selfgroups] self direct[eddirect[ed learning] lesslearning] lessdemanding in an academic sense (p. 949)demanding in an academic sense (p. 949)

curriculum innovation was associated withcurriculum innovation was associated withpositive changes in student wellpositive changes in student well--being but notbeing but noton performance. (p. 941)on performance. (p. 941)


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Student Nurse Stress IndexStudent Nurse Stress Index

Students were asked to complete indexStudents were asked to complete index

knowing that I believe (with empiricalknowing that I believe (with empirical

rational) that their stress levels are high.rational) that their stress levels are high.

As a faculty member I am an advocate andAs a faculty member I am an advocate and

foster facilitation of voice.foster facilitation of voice.

N= 60 Level 4N= 60 Level 4 BScNBScN studentsstudents


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Student Nurse Stress IndexStudent Nurse Stress Index

QuantitativeQuantitative

See table handoutSee table handout


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Student Nurse Stress IndexStudent Nurse Stress IndexQualitative Themes:Qualitative Themes:

1) Workload1) WorkloadContent Saturation; Additive CurriculumContent Saturation; Additive Curriculum

((GiddensGiddens & Brady, 2007;& Brady, 2007; IronsideIronside, 2004; Tanner,, 2004; Tanner,1989)1989)

2) Meaningless/Irrelevance2) Meaningless/Irrelevance

Practical Experience/Structural influence ofPractical Experience/Structural influence of

Clinical (Clinical (RydonRydon,, RollestonRolleston & Mackie 2006)& Mackie 2006)


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Student Nurse Stress IndexStudent Nurse Stress IndexQualitative Themes:Qualitative Themes:

3)3) Powerlessness (See Fig. 1, Handout)Powerlessness (See Fig. 1, Handout)

Credibility/Credibility/RankismRankism ((Clarke, 2008;Clarke, 2008; Curtis, Bowen & Reid,Curtis, Bowen & Reid,2007; Hall, 2004)2007; Hall, 2004) You have noYou have no credibiltycredibilty ;;Nursing students experiences of horizontal violenceNursing students experiences of horizontal violence

Common sources of stress associated withCommon sources of stress associated withdistress include academic items such asdistress include academic items such as

fear of failing,fear of failing,

lack of free time,lack of free time,

long hours of study andlong hours of study and

college response to student need.college response to student need. (Jones & Johnson, 1997,(Jones & Johnson, 1997,p. 480)p. 480)


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Thoughts to considerThoughts to consider

Is education student centered/self directedIs education student centered/self directed

in terms of autonomy and control whenin terms of autonomy and control whendemands are high & control is low?demands are high & control is low?ResistanceResistance

Is educationIs education meaningful in terms ofmeaningful in terms ofperspectives of nursing and nursingperspectives of nursing and nursingpractice?practice? RelevanceRelevance

3) Is education supportive in terms of3) Is education supportive in terms ofteacherteacher--student relationships?student relationships? RelationshipsRelationships


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Speculative Theory of StructuralSpeculative Theory of Structural

Aspects of StressAspects of Stress

Clinical

Knowledge/Oppressed

Group

Behaviour

Job

Demand-

Control-

Support

Hidden

Curriculum

Cohort

Effect

Generation

Me

(Twenge,

2006)

ResistantDisengaged

Entitled

Student


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In Praise of a TheoryIn Praise of a Theory

--Practice GapPractice Gap

SchoolClinical


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Reflect on education using theReflect on education using the

Three Cs of Professional/PracticalThree Cs of Professional/PracticalCurriculumCurriculum

1) Give them what they want? (Correspondence)1) Give them what they want? (Correspondence)Clinical or Reality WorkClinical or Reality Work

2) Better connection between academic work &2) Better connection between academic work &

clinical world? (Coherence)clinical world? (Coherence)

3) Critical pedagogy (Critical)3) Critical pedagogy (Critical)


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Accepting resistance in educationAccepting resistance in educationso what?so what?

Relationships (Honesty)Relationships (Honesty)

Relevance (Critical Thought)Relevance (Critical Thought)

Resistance (Passion)Resistance (Passion)

Source of student resistance was about much more than studentsSource of student resistance was about much more than studentssimply rejecting the value of education. Their resistance was ofsimply rejecting the value of education. Their resistance was oftentenreduced to this by many of the adults involved.reduced to this by many of the adults involved.

It turns out that their resistance was far more complex andIt turns out that their resistance was far more complex andseemingly quite logicalseemingly quite logical

I don't believe that there is a way to eliminate resistance. InI don't believe that there is a way to eliminate resistance. In fact, Ifact, Idon't believe that it should be eliminated.don't believe that it should be eliminated.

Resistance keeps professionals on their toes. It can be exhaustiResistance keeps professionals on their toes. It can be exhausting,ng,

physically and mentally.physically and mentally.In the final analysis, however, I believe that a healthy level oIn the final analysis, however, I believe that a healthy level offresistance can act to make the school the best it can be. This iresistance can act to make the school the best it can be. This issespecially likely when the professionals involved are reflectiveespecially likely when the professionals involved are reflective andandwilling to make changes. (willing to make changes. (SekayiSekayi, 2001, p. 420), 2001, p. 420)


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Accepting resistance in educationAccepting resistance in educationso what?so what?

Relationships (Honesty)Relationships (Honesty)

Relevance (Critical Thought)Relevance (Critical Thought)

Resistance (Passion)Resistance (Passion)

What must be urged is that the concept of resistance not be alloWhat must be urged is that the concept of resistance not be allowed towed tobecome a category indiscriminately hung over every expression ofbecome a category indiscriminately hung over every expression ofoppositional behaviour.oppositional behaviour.

Oppositional behaviour needs to be analyzed to see if it constitOppositional behaviour needs to be analyzed to see if it constitutes a formutes a formof resistance, which... Means uncovering its emancipatory intereof resistance, which... Means uncovering its emancipatory interests.sts.(Giroux, 1983, p. 110)(Giroux, 1983, p. 110)

the ultimate value of the notion of resistance has to be measu the ultimate value of the notion of resistance has to be measured againstred againstthe degree on which it not only prompts critical thinking and rethe degree on which it not only prompts critical thinking and reflectiveflectiveaction, but, more importantly, against the degree to which it coaction, but, more importantly, against the degree to which it contains thentains the

possibility of galvanizing collective political struggle aroundpossibility of galvanizing collective political struggle around the issues ofthe issues ofpower and social determination. (p. 111)power and social determination. (p. 111)


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Is Resistance Emancipatory?Is Resistance Emancipatory?

IsIs EmanicpatoryEmanicpatory Education Necessary?Education Necessary?

Is Emancipatory Education Possible?Is Emancipatory Education Possible?

WHERE TO FROM HERE?????????WHERE TO FROM HERE?????????

Thanks!!!!!Thanks!!!!!


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the structure of stress in nursing education

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