The Structure of Stress in Nursing Education

A Theoretical-Empirical Analysis C. E. Betts McMaster University NERU, Dec. 8, 2008

Sources of Data
Empirical/Feedback (Student Nurse Stress Index) Literature (both empirical and theoretical) Critical Theorizing Pseudo-Critical Ethnography

Professional socialization
Student & graduate nurses learn to think & act in ways defined for them by the traditionally dominant groups within the health system & which they accept as natural, common-sense views of social reality. Nursing education does not simply 'process students' or 'process knowledge'; it helps create & legitimize forms of consciousness which reinforce existing hegemonic structures. (Clare, 1993, p. 1034)

Professional socialization is challenged by: incongruities between education and industry difficulties in formalizing appropriate administrative and functional support for the NG, a growing expression by nurses of powerlessness within the health care system. (Boychuk Duchscher & Cowin, 2006, p. 1034)

Accountability of Education & Practice World

must acknowledge, understand, and work to resolve the oppressive socio-political context of the hospital environment if we expect to replenish and retain a motivated and energized nursing workforce. (Boychuk Duchscher & Cowin, 2006, p. 1034)

The Crisis of Nursing??

There is mounting evidence that the perception of nursing as a challenging, satisfying, & fulfilling vocation by societys youth is waning. (Boychuk-Duchscher & Cowin, 2006, p. 152) Challenges are: Shortage Stress/Burnout/Injury Rate Overworked/Underpaid Horizontal Violence/Hierarchical Rankism Devalued/Oppressed/Subjugated

Resolution: Shift to Emancipatory Foundations

[Emancipatory] pedagogy takes the problems & needs of students themselves as its starting point a pedagogy based on student experience encourages us to analyze the dominate forms of knowledge that shape student experiences Any emancipatory curriculum must emphasize student experience, which is intimately related to identity formation. (McLaren, 2002, p. 226)

Literature on Distress in Nursing Education

The level of distress, disengagement, apathy & at times perhaps even desperation, in nursing students, is becoming critical (Gibbons, Dempster & Moutray, 2008; Hall, 2004). Moreover, there are powerful structural aspects to this phenomenon. Preparing to become a nurse is associated with significant emotional distress and may carry a risk to the affective well-being of the student. (Jones & Johnson, 1997, p. 481)

Literature on Distress in Nursing Education

By desperation, I am referring to the condition of being without hope, feeling less than a full person, and seeing few options. Such desperation may be fostered, at least in part, by conditions of educational pressures. I refer to students feeling isolated, misunderstood, and dismissed. I also refer to faculty feeling overburdened with work and academic expectations associated with fulfillment of the faculty role and steep expectations for promotion and tenure. (Hall, 2004, p. 147)

Is There a Structure to Stress??

The relative lack of organizational level programmes to reduce work-related distress, and the scarcity of interventions targeting aspects of the work environment likely to contribute to such outcomes may have contributed to continuing high levels of distress in trained and student nurses. Recommendations regarding the future design, provision and evaluation of such work-site interventions include the further clarification of the structure of perceived stressors, and development of causal models of the stress process to identify the job characteristics `causing' work-related distress. (Jones & Johnson, 2000, p. 66) What about organizational (structural/institutional) stress and distress in school??????

Job Demands-Control-Support Model

states that psychological strain results not from a single aspect of the work environment, but from:
the joint effects of the demands of a work situation, & the range of decision-making freedom (discretion) available to the worker facing those demands. (Karasek, 1979, p. 287)

Application to University Students Results showed high levels of psychological stress & low levels of satisfaction, are both linked to high demands combined with low control. (Cotton, Dollard & de Jonge, 2002 p. 147) Levels of satisfaction have a direct impact on student performance & mediate the relationship between academic work control & performance. (Chambel & Curral, 2005, p. 135)

Nursing Students?
The Job Demands-Control-Support model has not been applied to nursing students BUT Staff nurses who experienced high psychological stress at work with little control over their job were significantly less empowered, less committed to the organization, and less satisfied with their jobs than those with lower levels of job strain. (Spence Laschinger et al, 2001, p. 238)

Is the introduction of a student-centred, problem-based curriculum associated with improvements in student nurse well-being and performance? (Jones & Johnston, 2006)

[PBL students] reported less distress in their first year of the course, they scored less well on comparable essay assignments and had greater sickness absence totals (p. 941) increased levels of support [from small groups] self direct[ed learning] less demanding in an academic sense (p. 949) curriculum innovation was associated with positive changes in student well-being but not on performance. (p. 941)

Student Nurse Stress Index

Students were asked to complete index knowing that I believe (with empirical rational) that their stress levels are high. As a faculty member I am an advocate and foster facilitation of voice. N= 60 Level 4 BScN students

Student Nurse Stress Index

Quantitative See table handout

Student Nurse Stress Index

Qualitative Themes: 1) Workload Content Saturation; Additive Curriculum (Giddens & Brady, 2007; Ironside, 2004; Tanner, 1989) 2) Meaningless/Irrelevance Practical Experience/Structural influence of Clinical (Rydon, Rolleston & Mackie 2006)

Student Nurse Stress Index

Qualitative Themes: 3) Powerlessness (See Fig. 1, Handout) Credibility/Rankism (Clarke, 2008; Curtis, Bowen & Reid, 2007; Hall, 2004) You have no credibilty ;
Nursing students experiences of horizontal violence

Common sources of stress associated with distress include academic items such as fear of failing, lack of free time, long hours of study and college response to student need. (Jones & Johnson, 1997,
p. 480)

Thoughts to consider
Is education student centered/self directed in terms of autonomy and control when demands are high & control is low? Resistance Is education meaningful in terms of perspectives of nursing and nursing practice? Relevance 3) Is education supportive in terms of teacher-student relationships? Relationships

Speculative Theory of Structural Aspects of Stress

Cohort Effect Generation Me (Twenge, 2006)

Clinical Knowledge/ Oppressed Group Behaviour

Resistant Disengaged Entitled Student

Hidden Curriculum

Job DemandControlSupport

In Praise of a Theory-Practice Gap

Clinical

School

Reflect on education using the Three Cs of Professional/Practical Curriculum

1) Give them what they want? (Correspondence) Clinical or Reality Work 2) Better connection between academic work & clinical world? (Coherence) 3) Critical pedagogy (Critical)

Accepting resistance in education so what?

Relationships (Honesty) Relevance (Critical Thought) Resistance (Passion)

Source of student resistance was about much more than students simply rejecting the value of education. Their resistance was often reduced to this by many of the adults involved. It turns out that their resistance was far more complex and seemingly quite logical I don't believe that there is a way to eliminate resistance. In fact, I don't believe that it should be eliminated. Resistance keeps professionals on their toes. It can be exhausting, physically and mentally. In the final analysis, however, I believe that a healthy level of resistance can act to make the school the best it can be. This is especially likely when the professionals involved are reflective and willing to make changes. (Sekayi, 2001, p. 420)

Accepting resistance in education so what?

Relationships (Honesty) Relevance (Critical Thought) Resistance (Passion)

What must be urged is that the concept of resistance not be allowed to become a category indiscriminately hung over every expression of oppositional behaviour. Oppositional behaviour needs to be analyzed to see if it constitutes a form of resistance, which... Means uncovering its emancipatory interests. (Giroux, 1983, p. 110) the ultimate value of the notion of resistance has to be measured against the degree on which it not only prompts critical thinking and reflective action, but, more importantly, against the degree to which it contains the possibility of galvanizing collective political struggle around the issues of power and social determination. (p. 111)

Is Resistance Emancipatory?
Is Emanicpatory Education Necessary? Is Emancipatory Education Possible? WHERE TO FROM HERE????????? Thanks!!!!!



Boychuk-Duchscher, J. E. & Cowin, L. S. (2006. The new graduates professional inheritance. Nursing Outlook, 54, 152-158. Chambel, M. J. & Curral, L. (2005). Stress in academic life: Work characteristics as predictors of student well-being and performance. Applied Psychology: An International Review, 54, 135-147. Clare, J. (1993) A challenge to the rhetoric of emancipation: Recreating a professional Culture. Journal of Advanced Nursing 18, 1033-1038. Clark, C. (2008). Student perspectives on faculty incivility in nursing education: An application of the concept of rankism. Nursing Outlook, 56, 4-8. Cotton, S. J., Dollard, M. F. & de Jonge, J. (2002). Stress and student job design: Satisfaction, well-being, and performance in university students. International Journal of Stress Management, 9(3), 147-162. Curtis, J., Bowen, I. & Reid, R. (2007). You have no credibility: Nursing students experiences of horizontal violence. Nurse Education in Practice, 7, 156-163. Giddens, J. & Brady, D. (2007). Resueing nursing education from content saturation: A case for a concept-based curriculum. Journal of Nursing Education, 46(2), 65-69. Giroux, H. A. (1983). Theory and resistance in education: A pedagogy of the opposition. Bergin & Garvey: Massachusetts. Hall, J. M. (2004). Dispelling desperation in nursing education. Nursing Outlook, 52, 147-154. Health Canada (2000). Best advice on stress risk management in the workplace Part 1. Available at: http://www.hc-sc.gc.ca/ewh-semt/pubs/occup-travail/stress-part1/foreword-avant_propos-eng.php Retrieved, September 20, 2008.

References Boychuk-Duchscher, J. E. & Cowin, L. S. (2006. The new graduates professional

References
Ironside, P. M. (2004). "Covering content" and teaching thinking: Deconstructing the additive curriculum. Journal of Nursing Education, 43, 5-12. Jones, M. C. & Johnston, D. W. (2006). Is the introduction of a student-centred, problem-based curriculum associated with improvements in student nurse well-being and performance? International Journal of Nursing Studies, 43, 941-952. Jones, M.C. & Johnston D.W. (2000). Reducing distress in first level and student nurses: A review of the applied stress management literature. Journal of Advanced Nursing, 32(1), 66-74. Jones, M. C. & Johnston, D.W. (1997). Distress, stress and coping in first-year student nurses. Journal of Advanced Nursing, 26, 475-482. Karasek, R. A. (1979). Job demands, job decision latitude and mental strain: Implications for job redesign. Administrative Science Quarterly, 24, 285-308. McLaren, P. (2002). Life in schools: An introduction to critical pedagogy in the Foundations of Education. New York: Longman. McMaster University Health Sciences. (2007/08). Undergraduate Nursing Education Program Handbook, Hamilton, Ont.: McMaster University. Sekayi, D. N. R. (2001). Intellectual indignation: Getting at the roots of student resistance in an alternative high school program. Education, 122(2), 414-422. Shields, C. M. (2003). Giving voice to students: Using the internet for data collection. Qualitative Research, 3(3), 397-414 Spence Laschinger, H, K., Finegan, J., Shamian, J. & Almost, J. (2001). Testing Karaseks Demands-Control Model in restructured healthcare settings effects of job strain on staff nurses quality of work life. JONA, 31(5), 233-243. Stevenson, A. & Harper, S. (2006). Workplace stress and the student learning experience. Quality Assurance in Education, 14(2), 167-178. Pitts, T. P. (1985). The covert curriculum what does nursing education really teach? Nursing Outlook, 33, 37-42.