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The role of nursing education in the perpetuation of inequality
Article
The role of nursing education in the perpetuation of inequality Brenda Happell A growing body of literature now strongly supports the view that undergraduate nursing students commence their education program with firm views about the most desirable and undesirable areas of practice. This paper reports the results of a longitudinal study of undergraduate nursing students’ career preferences in which attitudes on commencement are compared to attitudes immediately prior to the completion of the course. Differences in preferences were found between student choices at the beginning and end of the course, however the tendency for students to prefer areas of high technology and working with children and babies remains high despite some changes within these groupings. Similarly the unpopularity of psychiatric nursing, aged care, and community health remains an issue of concern despite some significant changes within these areas. The results are interpreted through a discussion of the role of nursing education in perpetuating the prejudices of students through portraying some areas of practice as inherently more desirable than others. ª 2002 Elsevier Science Ltd. All rights reserved.
Introduction
Brenda Happell BA (Hons), Dip Ed, PhD, Associate Professor, Director, Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing, University of Melbourne, Level 1, 723, Swanston Street, Carlton, Vic. 3010, Australia. Tel: +61 8344 0769; Fax: +61-9347-4172; E-mail: b.happell@ nursing.unimelb. edu.au (Requests for offprints to BH) Manuscript accepted: 9 April 2002
The concept of care is central to the philosophical underpinning of nursing. While medicine focuses on the cure of specific conditions, the primary domain of nursing is the provision of care to aid the recovery of the patient and/or support the adjustment to persistent disability or impending death. In striving for truly professional status, the nursing profession has emphasised the important role of caring, and spoken out against the notion that care is less important than the scientifically oriented and male dominated notion of cure (Johnstone, 1994; Millen, 1989). The degree to which such espoused views translate into reality must be measured against aspects of nursing practice from within, as well as from outside the profession. Research literature from as early as 1969 suggests that students and registered nurses hold a strong bias towards medical–surgical
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nursing as the most desirable areas to pursue their nursing career (Campbell, 1971; Caroselli-Karinja et al., 1988; Delora & Moses, 1969; Fielding, 1986; Gunter, 1971; Knowles & Faan, 1985; Reif & Estes, 1982). Working with children was also identified as a popular area by student nurses (Stevens & Dulhunty, 1992). Indeed the areas of nursing practice where care is most highly prominent, namely aged care, psychiatric/mental health nursing and community health nursing, tend to be unpopular areas (Arnswald, 1987; Caroselli-Karinja et al., 1988; Carter, 1986; Fielding, 1986; Peplau, 1989; Philipase et al., 1991; Stevens & Dulhunty, 1992, 1997; Stickney, 1985; Wright, 1988; Zukerberg, 1991). The extent to which the nursing profession itself should be accountable for this situation may well be questioned. Australian research has clearly indicated that undergraduate nursing students enter their nursing programme with positive views towards working with children and babies and in the
0260-6917/02/$ - see front mater ª 2002 Elsevier Science Ltd. All rights reserved doi:10.1016/S0260-6917(02)00104-1, available online at http://www.idealibrary.com on
The role of nursing education in the perpetuation of inequality
highly technical areas such as operating theatre and intensive/critical care. Aged care, psychiatric nursing, and community health nursing were significantly less popular choices with very few students selecting these as the areas where they would most like to work following graduation (Happell, 1999; Stevens & Dulhunty, 1992). Students tended to view working with children or with high levels of technology to be exciting and rewarding. Working with the community, the aged or the mentally ill tended to be viewed as dull, non-rewarding, having little effective purpose, and in some cases physically and/or emotionally dangerous. The degree to which nursing education can influence such attitudes and create a more holistic and egalitarian view of nursing practice has been the focus of research activity particularly in the areas of psychiatric nursing and aged care. More positive attitudes towards the care of the mentally ill were observed in students following their exposure to the theory and practice of psychiatric nursing (Bairan & Farnsworth, 1989; Collister, 1983; Hafner & Proctor, 1993; McLoughlin & Chalmers, 1991; Proctor & Hafner, 1991; Rushworth & Happell, 1998). Similarly education has been shown to improve the attitudes of students towards working with the aged. The research is, however, much less conclusive in the aged care field, with many studies demonstrating a decreased interest in aged care at the conclusion of the course (Stevens & Crouch, 1995). The available research however has tended to focus primarily on attitudinal change to the clientele and has not considered whether improved attitudes translate into an increased in the number of new graduates seeking a career in the areas of aged care and psychiatric nursing. Australian research (Stevens & Crouch, 1998; Stevens & Dulhunty, 1997) suggests that psychiatric nursing becomes only marginally more popular as the result of nursing education, and that aged care actually becomes less popular. The current study was proposed in order to ascertain a greater understanding of the reasons why students’ view particular areas as desirable and others as undesirable. The results of research such as this has significant
ª 2002 Elsevier Science Ltd. All rights reserved
implications in relation to workforce issues. The specialties of psychiatric nursing and aged care in particular are currently in a state of crisis in Australia as demonstrated through the inability to attract sufficient numbers of nurses to undertake employment in these area of practice. This situation is sufficiently serious to threaten the viability of the nursing workforce. In light of these concerns, the broad aim of this study is to investigate the rationale underpinning nursing students’ career preferences. A greater understanding of the impact of education on career preferences will be gained through a comparison between the popularity of various areas of nursing specialty between the commencement and completion of the undergraduate nursing course.
Method Procedure The current study involved the administration of a questionnaire based on the instrument developed by Stevens and Crouch (1995) to undergraduate nursing students. This methodological approach was chosen as it enabled the collection of data from a large number of students to provide the basis to measure changes over the course of educational exposure. The questionnaire was first administered at the start of the nursing course (stage 1), and readministered 3 years later at the end of their course (stage 2). The focus of this paper will be primarily directed towards the second phase of the study. Ethical considerations Ethics approval was obtained from each of the universities participating in the project. At the time of data collection students were provided with a full explanation of the study and a copy of the plain language statement was distributed with the questionnaires. They were informed that participation was purely on a voluntary basis. Students were advised to return the questionnaire blank if they did not wish to be involved and that the return of a
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completed questionnaire would be interpreted as their consent to participate. Sample At stage 1 of the research the questionnaire was administered to 834 first year undergraduate nursing students throughout Victoria, Australia during the first 3 weeks of the course. Seven hundred ninety three completed questionnaires were received, representing a return rate of 95%. At stage 2 the research 566 questionnaires were distributed with a return rate of 92% (n ¼ 521). Questionnaires were administered during class time to facilitate a high return rate. The lower sample size in the second stage is reflective of the natural attrition rate associated with undergraduate nursing education. Questionnaire The questionnaire utilised was modified from the instrument used by Stevens and Dulhunty (1992). Minor changes were made to reflect some of differences in nursing education and registration between the two states of Australia (Vic. and NSW). Prior to data collection a pilot study was conducted with 30 students. They were asked to complete the questionnaire and comment on the clarity of each question. The results support the reliability of the instrument and no further modifications were required. The students were required to rank nine areas of nursing practice, with number 1 representing the most popular and number 9 representing the least preferred choice. A series of open-ended questions was included to collect qualitative data to address the reasons behind the choices made. For example students were asked to provide reasons for their choice of the most preferred and least preferred option. Demographic data including age, gender, and previous nursing experience were also collected. Data analysis SPSS for Windows was used for data analysis. The mean, median, and mode were calculated
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for specialties to ascertain the popularity of each area. Wilcoxon signed ranks tests were used to assess the difference in ratings for each specialty between the start and end of the course, two-tailed P values are presented. Thematic analysis was used for the open-ended responses. The responses were coded according to the identified themes and the frequency for each response was calculated.
Findings Demographic profile Of the 793 participants at stage 1 83% (n ¼ 660) were female, 10% (n ¼ 80) are male, and 7% (n ¼ 53) did not record their gender. Seventy seven percent (n ¼ 613) of participants were aged 23 or less, with fewer than 12% (n ¼ 180) of participants over the age of 30. Seventy percent (n ¼ 556) of participants had no previous nursing experience. The nursing experience of the remaining 30% (n ¼ 237) included limited periods of work experience, varying years of experience as a state enrolled, psychiatric or mental retardation nurse. An analysis of demographic data at stage 2 was produced similar results other than for age, which reflected the time period between the two points of data collection. Stage 1 results At the start of the course the ranking of career preferences demonstrated strong preferences for two main areas of nursing practice. Working with children and midwifery were the two most popular areas, while intensive/critical care and operating theatre were also very popular. Conversely aged care, psychiatric nursing, and community health nursing were clearly not popular choices. More detailed information is presented in Table 1. In explaining the reasons for their most and least preferred career options, students revealed strong prejudices regarding the desirability of certain areas of nursing practice over others. Those who ranked working with children or midwifery as the most preferred area presented a positive view of the work environment and clientele.
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The role of nursing education in the perpetuation of inequality
Table 1 The relative popularity of nursing specialties assessed at the start of the nursing course (n ¼ 793) ordered by mean ranking Rank
Nursing specialty
1 2 3 4 5 6 7 8 9
With children Midwifery Intensive/critical Care Operating theatre General surgical General medical Community health Psychiatric nursing With elderly
a
Mean rankinga
Median rankinga
Mode of the rankinga
3.34 3.77 3.96 3.98 4.92 5.02 5.85 6.92 7.15
3.0 3.0 4.0 4.0 5.0 5.0 6.0 8.0 8.0
2.0 1.0 3.0 2.0 5.0 6.0 7.0 9.0 9.0
Rankings are from 1 ¼ most popular to 9 ¼ least popular.
Caring for children and babies was viewed as joyous, fulfilling, and worthwhile. The areas of operating theatre and intensive/critical care were viewed as action packed, exciting and interesting and the manipulation of technology was considered as highly skilled and highly responsible practice. The picture students portrayed of working with the elderly or in the area of psychiatric nursing indicated a very negative view of the clientele and the working environment. These areas were considered routine, dull and depressing and in some instances the work was considered to be almost futile with little possibility of recovery or significant improvement for patients. In the case of psychiatric nursing fear of being emotionally and/or physically harmed, and the perceived inability to cope with mentally ill patients were also common. The image of community health nursing was less negative; however students tended to view this area as less dynamic and providing less variety in clinical experience
than they could expect in a hospital environment. Stage 2 results The results obtained at the end of the course suggest that the career preferences of nursing students are not static and have been influenced during the 3 years of nursing education. The post-test ranking of career choices is presented in Table 2. Some notable differences in students’ career preferences have occurred at this stage with all of the areas ranked from 1 to 5 being different from those recorded at stage 1. Three of these changes were analysed as statistically significant. On closer analysis however it becomes apparent that the five most popular choices at stage 1 continue to be the five most popular at stage 2, with the difference reflecting a change in order. Surgical nursing demonstrated the most dramatic ascendancy, increasing in popularity
Table 2 The relative popularity of nursing specialties assessed at the end of the nursing course (n ¼ 521) ordered by mean ranking Mean rankinga Median rankinga
Rank
Nursing Specialty
1 2 3 4 5 6 7 8 9
Surgical nursing Intensive/critical Care Working with children Midwifery Operating theatre Community health nursing Medical nursing Psychiatric nursing Working with the elderly
a
3.90 4.28 4.31 4.53 4.78 4.78 4.86 5.95 7.45
4 4 4 4 5 5 5 7 8
Mode of the rankinga 2 1 2 1 5 7 5 9 9
Sig. (2-tailed) .000 .869 .354 .045 .000 .058 .081 .011 .000
Rankings are from 1 ¼ most popular to 9 ¼ least popular.
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from a ranking of five at pre-test to becoming clearly the most popular choice, with the difference in mean scores found to be highly significant. Intensive/critical care demonstrated a slight decrease in mean score, but overtook midwifery to be ranked at number 2. Working with children and midwifery both experienced declines in the mean score. In the case of midwifery this was found to be significant at with a P-value of .045. The main casualty of the top five was operating theatre, which declined from a ranking of 3–5, with the change in mean highly significant at .000. At the less popular end of the scale significant results were found in the areas of psychiatric nursing and working with the elderly. The popularity of psychiatric nursing demonstrated a significant increase although it continued to be ranked as the second least popular choice. Working with the elderly remained as last preference, demonstrated by a highly significant decrease in popularity. Overall there were only minor changes in rankings in the lower order, with medical nursing and community health nursing exchanging positions from 6 and 7.
Students’ reasons for the popularity of specific career preferences Analysis of the qualitative responses was undertaken to ascertain the extent to which the similarities and differences in career preferences at stage 2 are indicative of for example, an altered image or increased knowledge of nursing. An overview of the responses given is provided and supported by representative quotes from the students.
undergraduate programme and facilitate the development of a solid background for other areas of nursing practice in the future. The following quotes illustrate some of these issues: I enjoy the variety that general surgical areas offer. You are able to practise your nursing skills in a wide environment. [Surgical nursing] gives good general overall experience which would make me more employable if I wanted to travel or move cities. I feel more confident in taking care of this type of patient. Most of my clinical placements were in a surgical ward. Intensive/critical care Responses from students who ranked this area as their most preferred option indicate similar views to those given during the first stage. The intensive/critical care environment is perceived as dynamic, pressured, and cutting edge. It provides the opportunity to save lives and calls upon highly developed skills. The following student responses illustrate these views: I enjoy the knowledge that you have to acquire and use in intensive/critical care. Interesting, challenging, and rewarding. Very advanced nursing—providing patients with optimum level of care. I enjoy high dependency nursing as it involves the need to broaden my skills to many areas, i.e., emergency nursing. I enjoy learning new ‘‘modes of care’’ continuously.
Working with children Surgical nursing Students indicated that they found this an interesting, challenging, and rewarding area that exposed them to variety in procedures and offered the opportunity to see their patients become well. It was also viewed as an area that would provide opportunities for them to consolidate the skills learnt in the
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A positive attitude towards the clientele was again the predominant reason given for a desire to work with children. Students described a love of children and a desire to help them. The idea that this work environment would be challenging, interesting, and rewarding was also frequently asserted, as demonstrated by the following quotes:
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The role of nursing education in the perpetuation of inequality
I love working with children, very entertaining, keeps you going.
It is easier on my knees and back and I like the teamwork. More autonomy.
Because I can relate to them well. I like being with children due to their nature.
Theatre is fun and always busy. There appears to be more teamwork than any other area and it is challenging.
I relate well with children and enjoy caring for them. I feel it would be a satisfying career. Midwifery Students ranking midwifery as their most preferred area continued to demonstrate a highly positive view of the working environment. Childbirth was seen as a joyous occasion of which students would feel privileged to be a part. A desire to, and belief that they had the skills to, work effectively with babies and children was also commonly stated. The following student quotes illustrate some of these issues: As a midwife you are allowed to participate in a hugely important aspect of people’s lives and that is a privilege. I also find this area fascinating. There is more scope to be an independent practitioner too. I worked at the Rosebud Midwifery Unit and felt absolutely wonderful. The midwives said I had a way with patients. They responded well to me and I had enormous input to help the mothers. I feel I can do a great job here. An area I am very keen on. Having had the experience of childbirth gives you different insight.
Operating theatre The perceived dynamic nature of the perioperative environment continued to be highly emphasised. Students viewed this area as exciting, interesting, and challenging. In some instances the ability to observe the human body was considered a desirable aspect of this field of work. The following student quotes emphasise the positive aspects attributed to this area: I enjoy theatre as it is an advancing area that requires a large knowledge base.
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Students’ reasons for the unpopularity of specific career preferences Working with the elderly Aged care continues to be viewed as a sad and depressing environment, where the work is boring, repetitive, and physically taxing. Students frequently expressed frustration at working with elderly people who do not get better. The response that the students had worked in this area before and sought to broaden their experiences through different areas of practice was more common at the second stage of the research. This may reflect the fact that many undergraduate nursing students in Australia obtain part time work in nursing homes to supplement their income during their student years. The following quotes illustrate some of their attitudes towards aged care: I find that the elderly don’t ‘‘get better as such’’, they have more chronic conditions. I feel increased job satisfaction when I see that I have helped in recovery. I don’t want to put my back out with heavy lifting. I don’t think I could put up with one more story about ‘‘their days’’, 365 days a year. I’ve hated my clinical placements with the elderly. I think it was a bit boring for me. I worked in nursing homes during university and would like to do something different.
Psychiatric nursing Psychiatric nursing was one area of practice where there were notable changes in student responses between the pre-test and post-test phases. Fear of and intimidation by mentally ill
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people has become less frequent as an issue affecting the popularity of this area. The most common response now reflected the view that this area is not sufficiently exciting or rewarding. Insufficient knowledge or understanding of mentally ill people; the belief that students’ lacked the personal characteristics or qualities to perform in this environment; an image of psychiatric nursing as depressing, sad, stressful, and/or demanding place to work; and, a preference for other areas of practice, particularly medical–surgical nursing were other common explanations. Furthermore, the theoretical psychiatric nursing unit within the undergraduate programme was specifically mentioned in 1% of responses at having a negative impact on interest in this area. A further 10% indicated a negative clinical experience as adversely affecting their image of this specialty. The following quotes demonstrate some of the views of psychiatric nursing held by these students: I have no interest in psychiatric nursing and find it difficult to relate to the patients. There is not enough ‘hands on’ nursing work. I feel that I do very little for the patient. Often a cure is not in sight or cannot be attained. I have completed my psych [sic] nursing and I found that there was little job satisfaction for me, something that I didn’t enjoy. Psychiatric nursing is the area which interests me the least—I believe it would be very difficult and draining to work with such clients who have psychiatric difficulties regularly. Too slow and it is talking to people, not much practical. I did clinical placement in psychiatric nursing and did not enjoy it at all. Community health nursing Community health nursing showed a slight, though not statistically significant, increase in popularity. The most common reasons for ranking this area as least preferred had not
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changed substantially from the pre-test period. Students indicated a desire to work in a hospital environment which they perceived as being faster paced and providing more hands on experience, and providing more one: one contact with patients. As demonstrated in the following quotes: Boring! Dressings, meds and more dressings. Slow. I hated the district nursing placement. Showering is not something you do a degree for the privilege of doing.
Discussion The results of this research suggest that the impact of nursing education on students’ attitudes towards the desirability of specific areas of nursing practice as future career choices is limited. Some statistically significant changes were evident between choices at the start and end of the course, but most of these demonstrated changes in position between what were initially established as the most popular practice areas. Surgical nursing became the most popular choice while there were minor differences in the rankings of the other highly desirable areas. The more technologically driven areas of practice emerged to be the most popular by the end of the course (with the exception of operating theatre nursing which dropped from 3 to 5). This supports the findings of Kiger (1993) that on graduation the view of students that medical–surgical nursing is ‘real’ nursing has been strengthened. The work of Stevens and Crouch (1998) and Stevens and Dulhunty (1997) suggests that this translates into medical–surgical and ‘‘high tech’’ areas being that students tend to favour. It has been argued that the manipulation of technology brings the nurse closer to the world of medicine, by identifying with the concept of cure as opposed to the concept of care which is assumed to underpin the nursing role (Johnstone, 1994; Millen, 1989). This view has been supported by Australian research (Wilson & Retsas, 1997) which found that acute care and critical care nurses are more likely to highlight factors such as knowledge base, teaching skills, clinical
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The role of nursing education in the perpetuation of inequality
skills, and achievement orientation as most important in their work place. Characteristics associated with caring including compassion, empathy and a holistic view of nursing care were less frequently articulated. The latter characteristics were more commonly attributed to nurses employed in the aged care environment, which further support the view that ‘caring’ is less highly regarded than ‘curing.’ The privilege of curing over caring provides a significant contribution to explaining the popularity of the technologically driven areas of nursing in comparison to the more care focused areas of aged care, psychiatric nursing, and community mental health nursing. The results of the current study support this view. Again the differences in career preferences represented a minor change in the order of the bottom 4. Although a highly significant increase in the popularity of psychiatric nursing was evident between the two time periods, psychiatric nursing continues to be ranked at number 8. Working with the elderly not only remained at number 9 but became significantly less popular. The minor changes between medical nursing and community were not found to be statistically significant. The popularity of midwifery and working with children does not, however, fit neatly into this mould. While neither area is devoid from the use of technology, responses from students who listed these two areas as their most preferred rarely referred to technology as a reason. Clearly this demonstrates the preference for youth over age generations (Stevens & Crouch, 1995; Stickney, 1985; Wright, 1988; Zukerberg, 1991). Participants in this study clearly demonstrated the view that older people do not get better, and it is more rewarding and fulfilling to contribute to the care of people with a future. This issue must be viewed as one of serious concern to the nursing profession. It may be stated that all areas of nursing practice are equal but from the results of this research it would appear that some are more equal than others. To continue on the present path is tantamount to saying that the manipulation of technology is more important than the essence of nursing itself.
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The most obvious place to address this is in Schools of Nursing. Curricula need to be radically reviewed, not just in terms of revising the content to reflect a more even exposure to areas of nursing practice, but to examine approaches to teaching that reinforce the image that medical–surgical nursing equates to nursing. The same ethos needs to be reflected by our clinical partners. Students need to view clinical placements in all areas of practice as equally valuable, and if they express their desire to pursue a career in a less popular area such as psychiatric nursing or aged care, this should be respected and no attempts made to deter them. Statements like: ‘‘what a smart girl like you?’’ or ‘‘you need to consolidate your skills in a general hospital first’’ do little to improve the image of already marginalised specialties. The strength of the nursing profession will rest in no small part on its ability to promote itself as a profession of diverse practice and focus, but with the single aim to promote the contribution nursing can make to improving the health outcomes of consumers, across the life span, varying health care needs.
References Arnswald L 1987 Are Psychiatric Nurses as endangered species? Journal of Psychosocial Nursing 25: 31–33 Bairan A, Farnsworth B 1989 Attitudes toward mental illness: Does a psychiatric nursing course make a difference? Archives of Psychiatric Nursing 3(6): 351–357 Campbell ME 1971 Study of the attitudes of nursing personnel towards geriatric patients. Nursing Research 20: 147–151 Caroselli-Karinja MF, McGowan J, Penn SM 1988 Internship programs are safeguarding the future of psychiatric nursing. Journal of Psychosocial Nursing 26(8): 28–31 Carter EW 1986 Psychiatric Nursing. Journal of Psychosocial Nursing and Mental Health Services 24(6): 26–30 Collister B 1983 The value of psychiatric experience in general nurse training. Nursing Times 79(29): 66–69 Delora JR, Moses D 1969 Specialty preferences and characteristics of nursing students in baccalaureate programs. Nursing Research 2(1): 38–43 Fielding P 1986 Attitudes Revisited. Whitefriars Press, Tonbridge Gunter LM 1971 Students attitudes towards geriatric nursing. Nursing Outlook 19(7): 466–469
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Hafner J, Proctor N 1993 Student nurse’s specialty choices: The influence of personality and education. Contemporary Nurse 2(1): 38–43 Happell B 1999 ‘‘When I grow up I want to be a . . .?’’ Where undergraduate student nurses want to work after graduation. Journal of Advanced Nursing 29(2): 499–505 Johnstone M 1994 Nursing and the Injustices of the Law. Harcourt Brace, Australia Kiger AM 1993 Accord and discord in students’ images of nursing. Journal of Nursing Education 32(7): 309–317 Knowles L, Faan C 1985 Attitudes affect quality care. Journal of Gerontological Nursing 11(8): 35–38 McLoughlin K, Chalmers J 1991 Student attitudes towards mental illness: Impact of education and exposure. Australian Journal of Mental Health Nursing 1: 12–17 Millen N 1989 The Factors Behind the Emergent Militancy of Nurses in the Pursuit of Work Satisfaction and Professionalism. In: Lupton GM, Najman JM (eds). Sociology of Health and Illness. MacMillan, Australia Peplau H 1989 Future directions in psychiatric nursing from the perspective of history. Journal of Psychosocial Nursing 27(2): 18–28 Proctor N, Hafner J 1991 Student nurses’ attitudes to psychiatry: the influence of training and personality. Journal of Advanced Nursing 16: 849–854 Reif L, Estes C 1982 Long term care: new options for professional nursing. In: Aitken L (ed). Nursing in the 1980s: Crises, Opportunities and Challenges. Lippincott, Philadelphia
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Rushworth L, Happell B 1998 Psychiatric nursing education: doing the impossible? Archives of Psychiatric Nursing 12(6): 319–325 Stevens JA, Crouch M 1995 Who cares about care in nursing education? International Journal of Nursing Studies 32(3): 233–242 Stevens JA, Crouch M 1998 Frankenstein’s nurse! What are schools of nursing creating? Collegian: Journal of the Royal College of Nursing, Australia 5(1): 10–15 Stevens JA, Dulhunty GM 1992 New South Wales Nursing Students’ attitudes towards a career in mental health. In: Proceedings, Australian College of Mental Health Nurses. 18th Annual Convention. Ballarat Stevens JA, Dulhunty GM 1997 A career with mentally-ill people: An unlikely destination for graduates of pre-registration nursing programs. The Australian Electronic Journal of Nursing Education. Available from Stickney C 1985 Wanted innovated nurses for long-term care. Geriatric Nursing 6: 342–344 Wilson JM, Retsas AP 1997 Personal constructs of nursing practice: A comparative analysis of three groups of Australian nurses. International Journal of Nursing Studies 34(1): 63–71 Wright L 1988 A reconceptualisation of the ‘‘Negative staff attitudes and poor care in nursing homes’’ assumption. The Gerontologist 28(6): 813–820 Zukerberg E 1991 What’s a sharp nurse like you doing in LTC [editorial]? Geriatric Nursing 12: 113
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The role of nursing education in the perpetuation of inequality Brenda Happell A growing body of literature now strongly supports the view that undergraduate nursing students commence their education program with firm views about the most desirable and undesirable areas of practice. This paper reports the results of a longitudinal study of undergraduate nursing students’ career preferences in which attitudes on commencement are compared to attitudes immediately prior to the completion of the course. Differences in preferences were found between student choices at the beginning and end of the course, however the tendency for students to prefer areas of high technology and working with children and babies remains high despite some changes within these groupings. Similarly the unpopularity of psychiatric nursing, aged care, and community health remains an issue of concern despite some significant changes within these areas. The results are interpreted through a discussion of the role of nursing education in perpetuating the prejudices of students through portraying some areas of practice as inherently more desirable than others. ª 2002 Elsevier Science Ltd. All rights reserved.
Introduction
Brenda Happell BA (Hons), Dip Ed, PhD, Associate Professor, Director, Centre for Psychiatric Nursing Research and Practice, School of Postgraduate Nursing, University of Melbourne, Level 1, 723, Swanston Street, Carlton, Vic. 3010, Australia. Tel: +61 8344 0769; Fax: +61-9347-4172; E-mail: b.happell@ nursing.unimelb. edu.au (Requests for offprints to BH) Manuscript accepted: 9 April 2002
The concept of care is central to the philosophical underpinning of nursing. While medicine focuses on the cure of specific conditions, the primary domain of nursing is the provision of care to aid the recovery of the patient and/or support the adjustment to persistent disability or impending death. In striving for truly professional status, the nursing profession has emphasised the important role of caring, and spoken out against the notion that care is less important than the scientifically oriented and male dominated notion of cure (Johnstone, 1994; Millen, 1989). The degree to which such espoused views translate into reality must be measured against aspects of nursing practice from within, as well as from outside the profession. Research literature from as early as 1969 suggests that students and registered nurses hold a strong bias towards medical–surgical
632 Nurse Education Today (2002) 22, 632–640
nursing as the most desirable areas to pursue their nursing career (Campbell, 1971; Caroselli-Karinja et al., 1988; Delora & Moses, 1969; Fielding, 1986; Gunter, 1971; Knowles & Faan, 1985; Reif & Estes, 1982). Working with children was also identified as a popular area by student nurses (Stevens & Dulhunty, 1992). Indeed the areas of nursing practice where care is most highly prominent, namely aged care, psychiatric/mental health nursing and community health nursing, tend to be unpopular areas (Arnswald, 1987; Caroselli-Karinja et al., 1988; Carter, 1986; Fielding, 1986; Peplau, 1989; Philipase et al., 1991; Stevens & Dulhunty, 1992, 1997; Stickney, 1985; Wright, 1988; Zukerberg, 1991). The extent to which the nursing profession itself should be accountable for this situation may well be questioned. Australian research has clearly indicated that undergraduate nursing students enter their nursing programme with positive views towards working with children and babies and in the
0260-6917/02/$ - see front mater ª 2002 Elsevier Science Ltd. All rights reserved doi:10.1016/S0260-6917(02)00104-1, available online at http://www.idealibrary.com on
The role of nursing education in the perpetuation of inequality
highly technical areas such as operating theatre and intensive/critical care. Aged care, psychiatric nursing, and community health nursing were significantly less popular choices with very few students selecting these as the areas where they would most like to work following graduation (Happell, 1999; Stevens & Dulhunty, 1992). Students tended to view working with children or with high levels of technology to be exciting and rewarding. Working with the community, the aged or the mentally ill tended to be viewed as dull, non-rewarding, having little effective purpose, and in some cases physically and/or emotionally dangerous. The degree to which nursing education can influence such attitudes and create a more holistic and egalitarian view of nursing practice has been the focus of research activity particularly in the areas of psychiatric nursing and aged care. More positive attitudes towards the care of the mentally ill were observed in students following their exposure to the theory and practice of psychiatric nursing (Bairan & Farnsworth, 1989; Collister, 1983; Hafner & Proctor, 1993; McLoughlin & Chalmers, 1991; Proctor & Hafner, 1991; Rushworth & Happell, 1998). Similarly education has been shown to improve the attitudes of students towards working with the aged. The research is, however, much less conclusive in the aged care field, with many studies demonstrating a decreased interest in aged care at the conclusion of the course (Stevens & Crouch, 1995). The available research however has tended to focus primarily on attitudinal change to the clientele and has not considered whether improved attitudes translate into an increased in the number of new graduates seeking a career in the areas of aged care and psychiatric nursing. Australian research (Stevens & Crouch, 1998; Stevens & Dulhunty, 1997) suggests that psychiatric nursing becomes only marginally more popular as the result of nursing education, and that aged care actually becomes less popular. The current study was proposed in order to ascertain a greater understanding of the reasons why students’ view particular areas as desirable and others as undesirable. The results of research such as this has significant
ª 2002 Elsevier Science Ltd. All rights reserved
implications in relation to workforce issues. The specialties of psychiatric nursing and aged care in particular are currently in a state of crisis in Australia as demonstrated through the inability to attract sufficient numbers of nurses to undertake employment in these area of practice. This situation is sufficiently serious to threaten the viability of the nursing workforce. In light of these concerns, the broad aim of this study is to investigate the rationale underpinning nursing students’ career preferences. A greater understanding of the impact of education on career preferences will be gained through a comparison between the popularity of various areas of nursing specialty between the commencement and completion of the undergraduate nursing course.
Method Procedure The current study involved the administration of a questionnaire based on the instrument developed by Stevens and Crouch (1995) to undergraduate nursing students. This methodological approach was chosen as it enabled the collection of data from a large number of students to provide the basis to measure changes over the course of educational exposure. The questionnaire was first administered at the start of the nursing course (stage 1), and readministered 3 years later at the end of their course (stage 2). The focus of this paper will be primarily directed towards the second phase of the study. Ethical considerations Ethics approval was obtained from each of the universities participating in the project. At the time of data collection students were provided with a full explanation of the study and a copy of the plain language statement was distributed with the questionnaires. They were informed that participation was purely on a voluntary basis. Students were advised to return the questionnaire blank if they did not wish to be involved and that the return of a
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completed questionnaire would be interpreted as their consent to participate. Sample At stage 1 of the research the questionnaire was administered to 834 first year undergraduate nursing students throughout Victoria, Australia during the first 3 weeks of the course. Seven hundred ninety three completed questionnaires were received, representing a return rate of 95%. At stage 2 the research 566 questionnaires were distributed with a return rate of 92% (n ¼ 521). Questionnaires were administered during class time to facilitate a high return rate. The lower sample size in the second stage is reflective of the natural attrition rate associated with undergraduate nursing education. Questionnaire The questionnaire utilised was modified from the instrument used by Stevens and Dulhunty (1992). Minor changes were made to reflect some of differences in nursing education and registration between the two states of Australia (Vic. and NSW). Prior to data collection a pilot study was conducted with 30 students. They were asked to complete the questionnaire and comment on the clarity of each question. The results support the reliability of the instrument and no further modifications were required. The students were required to rank nine areas of nursing practice, with number 1 representing the most popular and number 9 representing the least preferred choice. A series of open-ended questions was included to collect qualitative data to address the reasons behind the choices made. For example students were asked to provide reasons for their choice of the most preferred and least preferred option. Demographic data including age, gender, and previous nursing experience were also collected. Data analysis SPSS for Windows was used for data analysis. The mean, median, and mode were calculated
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for specialties to ascertain the popularity of each area. Wilcoxon signed ranks tests were used to assess the difference in ratings for each specialty between the start and end of the course, two-tailed P values are presented. Thematic analysis was used for the open-ended responses. The responses were coded according to the identified themes and the frequency for each response was calculated.
Findings Demographic profile Of the 793 participants at stage 1 83% (n ¼ 660) were female, 10% (n ¼ 80) are male, and 7% (n ¼ 53) did not record their gender. Seventy seven percent (n ¼ 613) of participants were aged 23 or less, with fewer than 12% (n ¼ 180) of participants over the age of 30. Seventy percent (n ¼ 556) of participants had no previous nursing experience. The nursing experience of the remaining 30% (n ¼ 237) included limited periods of work experience, varying years of experience as a state enrolled, psychiatric or mental retardation nurse. An analysis of demographic data at stage 2 was produced similar results other than for age, which reflected the time period between the two points of data collection. Stage 1 results At the start of the course the ranking of career preferences demonstrated strong preferences for two main areas of nursing practice. Working with children and midwifery were the two most popular areas, while intensive/critical care and operating theatre were also very popular. Conversely aged care, psychiatric nursing, and community health nursing were clearly not popular choices. More detailed information is presented in Table 1. In explaining the reasons for their most and least preferred career options, students revealed strong prejudices regarding the desirability of certain areas of nursing practice over others. Those who ranked working with children or midwifery as the most preferred area presented a positive view of the work environment and clientele.
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The role of nursing education in the perpetuation of inequality
Table 1 The relative popularity of nursing specialties assessed at the start of the nursing course (n ¼ 793) ordered by mean ranking Rank
Nursing specialty
1 2 3 4 5 6 7 8 9
With children Midwifery Intensive/critical Care Operating theatre General surgical General medical Community health Psychiatric nursing With elderly
a
Mean rankinga
Median rankinga
Mode of the rankinga
3.34 3.77 3.96 3.98 4.92 5.02 5.85 6.92 7.15
3.0 3.0 4.0 4.0 5.0 5.0 6.0 8.0 8.0
2.0 1.0 3.0 2.0 5.0 6.0 7.0 9.0 9.0
Rankings are from 1 ¼ most popular to 9 ¼ least popular.
Caring for children and babies was viewed as joyous, fulfilling, and worthwhile. The areas of operating theatre and intensive/critical care were viewed as action packed, exciting and interesting and the manipulation of technology was considered as highly skilled and highly responsible practice. The picture students portrayed of working with the elderly or in the area of psychiatric nursing indicated a very negative view of the clientele and the working environment. These areas were considered routine, dull and depressing and in some instances the work was considered to be almost futile with little possibility of recovery or significant improvement for patients. In the case of psychiatric nursing fear of being emotionally and/or physically harmed, and the perceived inability to cope with mentally ill patients were also common. The image of community health nursing was less negative; however students tended to view this area as less dynamic and providing less variety in clinical experience
than they could expect in a hospital environment. Stage 2 results The results obtained at the end of the course suggest that the career preferences of nursing students are not static and have been influenced during the 3 years of nursing education. The post-test ranking of career choices is presented in Table 2. Some notable differences in students’ career preferences have occurred at this stage with all of the areas ranked from 1 to 5 being different from those recorded at stage 1. Three of these changes were analysed as statistically significant. On closer analysis however it becomes apparent that the five most popular choices at stage 1 continue to be the five most popular at stage 2, with the difference reflecting a change in order. Surgical nursing demonstrated the most dramatic ascendancy, increasing in popularity
Table 2 The relative popularity of nursing specialties assessed at the end of the nursing course (n ¼ 521) ordered by mean ranking Mean rankinga Median rankinga
Rank
Nursing Specialty
1 2 3 4 5 6 7 8 9
Surgical nursing Intensive/critical Care Working with children Midwifery Operating theatre Community health nursing Medical nursing Psychiatric nursing Working with the elderly
a
3.90 4.28 4.31 4.53 4.78 4.78 4.86 5.95 7.45
4 4 4 4 5 5 5 7 8
Mode of the rankinga 2 1 2 1 5 7 5 9 9
Sig. (2-tailed) .000 .869 .354 .045 .000 .058 .081 .011 .000
Rankings are from 1 ¼ most popular to 9 ¼ least popular.
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from a ranking of five at pre-test to becoming clearly the most popular choice, with the difference in mean scores found to be highly significant. Intensive/critical care demonstrated a slight decrease in mean score, but overtook midwifery to be ranked at number 2. Working with children and midwifery both experienced declines in the mean score. In the case of midwifery this was found to be significant at with a P-value of .045. The main casualty of the top five was operating theatre, which declined from a ranking of 3–5, with the change in mean highly significant at .000. At the less popular end of the scale significant results were found in the areas of psychiatric nursing and working with the elderly. The popularity of psychiatric nursing demonstrated a significant increase although it continued to be ranked as the second least popular choice. Working with the elderly remained as last preference, demonstrated by a highly significant decrease in popularity. Overall there were only minor changes in rankings in the lower order, with medical nursing and community health nursing exchanging positions from 6 and 7.
Students’ reasons for the popularity of specific career preferences Analysis of the qualitative responses was undertaken to ascertain the extent to which the similarities and differences in career preferences at stage 2 are indicative of for example, an altered image or increased knowledge of nursing. An overview of the responses given is provided and supported by representative quotes from the students.
undergraduate programme and facilitate the development of a solid background for other areas of nursing practice in the future. The following quotes illustrate some of these issues: I enjoy the variety that general surgical areas offer. You are able to practise your nursing skills in a wide environment. [Surgical nursing] gives good general overall experience which would make me more employable if I wanted to travel or move cities. I feel more confident in taking care of this type of patient. Most of my clinical placements were in a surgical ward. Intensive/critical care Responses from students who ranked this area as their most preferred option indicate similar views to those given during the first stage. The intensive/critical care environment is perceived as dynamic, pressured, and cutting edge. It provides the opportunity to save lives and calls upon highly developed skills. The following student responses illustrate these views: I enjoy the knowledge that you have to acquire and use in intensive/critical care. Interesting, challenging, and rewarding. Very advanced nursing—providing patients with optimum level of care. I enjoy high dependency nursing as it involves the need to broaden my skills to many areas, i.e., emergency nursing. I enjoy learning new ‘‘modes of care’’ continuously.
Working with children Surgical nursing Students indicated that they found this an interesting, challenging, and rewarding area that exposed them to variety in procedures and offered the opportunity to see their patients become well. It was also viewed as an area that would provide opportunities for them to consolidate the skills learnt in the
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A positive attitude towards the clientele was again the predominant reason given for a desire to work with children. Students described a love of children and a desire to help them. The idea that this work environment would be challenging, interesting, and rewarding was also frequently asserted, as demonstrated by the following quotes:
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The role of nursing education in the perpetuation of inequality
I love working with children, very entertaining, keeps you going.
It is easier on my knees and back and I like the teamwork. More autonomy.
Because I can relate to them well. I like being with children due to their nature.
Theatre is fun and always busy. There appears to be more teamwork than any other area and it is challenging.
I relate well with children and enjoy caring for them. I feel it would be a satisfying career. Midwifery Students ranking midwifery as their most preferred area continued to demonstrate a highly positive view of the working environment. Childbirth was seen as a joyous occasion of which students would feel privileged to be a part. A desire to, and belief that they had the skills to, work effectively with babies and children was also commonly stated. The following student quotes illustrate some of these issues: As a midwife you are allowed to participate in a hugely important aspect of people’s lives and that is a privilege. I also find this area fascinating. There is more scope to be an independent practitioner too. I worked at the Rosebud Midwifery Unit and felt absolutely wonderful. The midwives said I had a way with patients. They responded well to me and I had enormous input to help the mothers. I feel I can do a great job here. An area I am very keen on. Having had the experience of childbirth gives you different insight.
Operating theatre The perceived dynamic nature of the perioperative environment continued to be highly emphasised. Students viewed this area as exciting, interesting, and challenging. In some instances the ability to observe the human body was considered a desirable aspect of this field of work. The following student quotes emphasise the positive aspects attributed to this area: I enjoy theatre as it is an advancing area that requires a large knowledge base.
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Students’ reasons for the unpopularity of specific career preferences Working with the elderly Aged care continues to be viewed as a sad and depressing environment, where the work is boring, repetitive, and physically taxing. Students frequently expressed frustration at working with elderly people who do not get better. The response that the students had worked in this area before and sought to broaden their experiences through different areas of practice was more common at the second stage of the research. This may reflect the fact that many undergraduate nursing students in Australia obtain part time work in nursing homes to supplement their income during their student years. The following quotes illustrate some of their attitudes towards aged care: I find that the elderly don’t ‘‘get better as such’’, they have more chronic conditions. I feel increased job satisfaction when I see that I have helped in recovery. I don’t want to put my back out with heavy lifting. I don’t think I could put up with one more story about ‘‘their days’’, 365 days a year. I’ve hated my clinical placements with the elderly. I think it was a bit boring for me. I worked in nursing homes during university and would like to do something different.
Psychiatric nursing Psychiatric nursing was one area of practice where there were notable changes in student responses between the pre-test and post-test phases. Fear of and intimidation by mentally ill
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people has become less frequent as an issue affecting the popularity of this area. The most common response now reflected the view that this area is not sufficiently exciting or rewarding. Insufficient knowledge or understanding of mentally ill people; the belief that students’ lacked the personal characteristics or qualities to perform in this environment; an image of psychiatric nursing as depressing, sad, stressful, and/or demanding place to work; and, a preference for other areas of practice, particularly medical–surgical nursing were other common explanations. Furthermore, the theoretical psychiatric nursing unit within the undergraduate programme was specifically mentioned in 1% of responses at having a negative impact on interest in this area. A further 10% indicated a negative clinical experience as adversely affecting their image of this specialty. The following quotes demonstrate some of the views of psychiatric nursing held by these students: I have no interest in psychiatric nursing and find it difficult to relate to the patients. There is not enough ‘hands on’ nursing work. I feel that I do very little for the patient. Often a cure is not in sight or cannot be attained. I have completed my psych [sic] nursing and I found that there was little job satisfaction for me, something that I didn’t enjoy. Psychiatric nursing is the area which interests me the least—I believe it would be very difficult and draining to work with such clients who have psychiatric difficulties regularly. Too slow and it is talking to people, not much practical. I did clinical placement in psychiatric nursing and did not enjoy it at all. Community health nursing Community health nursing showed a slight, though not statistically significant, increase in popularity. The most common reasons for ranking this area as least preferred had not
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changed substantially from the pre-test period. Students indicated a desire to work in a hospital environment which they perceived as being faster paced and providing more hands on experience, and providing more one: one contact with patients. As demonstrated in the following quotes: Boring! Dressings, meds and more dressings. Slow. I hated the district nursing placement. Showering is not something you do a degree for the privilege of doing.
Discussion The results of this research suggest that the impact of nursing education on students’ attitudes towards the desirability of specific areas of nursing practice as future career choices is limited. Some statistically significant changes were evident between choices at the start and end of the course, but most of these demonstrated changes in position between what were initially established as the most popular practice areas. Surgical nursing became the most popular choice while there were minor differences in the rankings of the other highly desirable areas. The more technologically driven areas of practice emerged to be the most popular by the end of the course (with the exception of operating theatre nursing which dropped from 3 to 5). This supports the findings of Kiger (1993) that on graduation the view of students that medical–surgical nursing is ‘real’ nursing has been strengthened. The work of Stevens and Crouch (1998) and Stevens and Dulhunty (1997) suggests that this translates into medical–surgical and ‘‘high tech’’ areas being that students tend to favour. It has been argued that the manipulation of technology brings the nurse closer to the world of medicine, by identifying with the concept of cure as opposed to the concept of care which is assumed to underpin the nursing role (Johnstone, 1994; Millen, 1989). This view has been supported by Australian research (Wilson & Retsas, 1997) which found that acute care and critical care nurses are more likely to highlight factors such as knowledge base, teaching skills, clinical
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The role of nursing education in the perpetuation of inequality
skills, and achievement orientation as most important in their work place. Characteristics associated with caring including compassion, empathy and a holistic view of nursing care were less frequently articulated. The latter characteristics were more commonly attributed to nurses employed in the aged care environment, which further support the view that ‘caring’ is less highly regarded than ‘curing.’ The privilege of curing over caring provides a significant contribution to explaining the popularity of the technologically driven areas of nursing in comparison to the more care focused areas of aged care, psychiatric nursing, and community mental health nursing. The results of the current study support this view. Again the differences in career preferences represented a minor change in the order of the bottom 4. Although a highly significant increase in the popularity of psychiatric nursing was evident between the two time periods, psychiatric nursing continues to be ranked at number 8. Working with the elderly not only remained at number 9 but became significantly less popular. The minor changes between medical nursing and community were not found to be statistically significant. The popularity of midwifery and working with children does not, however, fit neatly into this mould. While neither area is devoid from the use of technology, responses from students who listed these two areas as their most preferred rarely referred to technology as a reason. Clearly this demonstrates the preference for youth over age generations (Stevens & Crouch, 1995; Stickney, 1985; Wright, 1988; Zukerberg, 1991). Participants in this study clearly demonstrated the view that older people do not get better, and it is more rewarding and fulfilling to contribute to the care of people with a future. This issue must be viewed as one of serious concern to the nursing profession. It may be stated that all areas of nursing practice are equal but from the results of this research it would appear that some are more equal than others. To continue on the present path is tantamount to saying that the manipulation of technology is more important than the essence of nursing itself.
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The most obvious place to address this is in Schools of Nursing. Curricula need to be radically reviewed, not just in terms of revising the content to reflect a more even exposure to areas of nursing practice, but to examine approaches to teaching that reinforce the image that medical–surgical nursing equates to nursing. The same ethos needs to be reflected by our clinical partners. Students need to view clinical placements in all areas of practice as equally valuable, and if they express their desire to pursue a career in a less popular area such as psychiatric nursing or aged care, this should be respected and no attempts made to deter them. Statements like: ‘‘what a smart girl like you?’’ or ‘‘you need to consolidate your skills in a general hospital first’’ do little to improve the image of already marginalised specialties. The strength of the nursing profession will rest in no small part on its ability to promote itself as a profession of diverse practice and focus, but with the single aim to promote the contribution nursing can make to improving the health outcomes of consumers, across the life span, varying health care needs.
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Hafner J, Proctor N 1993 Student nurse’s specialty choices: The influence of personality and education. Contemporary Nurse 2(1): 38–43 Happell B 1999 ‘‘When I grow up I want to be a . . .?’’ Where undergraduate student nurses want to work after graduation. Journal of Advanced Nursing 29(2): 499–505 Johnstone M 1994 Nursing and the Injustices of the Law. Harcourt Brace, Australia Kiger AM 1993 Accord and discord in students’ images of nursing. Journal of Nursing Education 32(7): 309–317 Knowles L, Faan C 1985 Attitudes affect quality care. Journal of Gerontological Nursing 11(8): 35–38 McLoughlin K, Chalmers J 1991 Student attitudes towards mental illness: Impact of education and exposure. Australian Journal of Mental Health Nursing 1: 12–17 Millen N 1989 The Factors Behind the Emergent Militancy of Nurses in the Pursuit of Work Satisfaction and Professionalism. In: Lupton GM, Najman JM (eds). Sociology of Health and Illness. MacMillan, Australia Peplau H 1989 Future directions in psychiatric nursing from the perspective of history. Journal of Psychosocial Nursing 27(2): 18–28 Proctor N, Hafner J 1991 Student nurses’ attitudes to psychiatry: the influence of training and personality. Journal of Advanced Nursing 16: 849–854 Reif L, Estes C 1982 Long term care: new options for professional nursing. In: Aitken L (ed). Nursing in the 1980s: Crises, Opportunities and Challenges. Lippincott, Philadelphia
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Rushworth L, Happell B 1998 Psychiatric nursing education: doing the impossible? Archives of Psychiatric Nursing 12(6): 319–325 Stevens JA, Crouch M 1995 Who cares about care in nursing education? International Journal of Nursing Studies 32(3): 233–242 Stevens JA, Crouch M 1998 Frankenstein’s nurse! What are schools of nursing creating? Collegian: Journal of the Royal College of Nursing, Australia 5(1): 10–15 Stevens JA, Dulhunty GM 1992 New South Wales Nursing Students’ attitudes towards a career in mental health. In: Proceedings, Australian College of Mental Health Nurses. 18th Annual Convention. Ballarat Stevens JA, Dulhunty GM 1997 A career with mentally-ill people: An unlikely destination for graduates of pre-registration nursing programs. The Australian Electronic Journal of Nursing Education. Available from
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