who cares about care in nursing education?

Pergamon Inr J. Nur., Sad.. Vol. 32. No. 3, pp. 233-242. 1995

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Who cares about care in nursing education?*

JOHN STEVENS School of’ Nursing und Health Administration, Charles Sturt University, Bathurst, New South Wales, Austrulia

MIRA CROUCH School of Sociology, UniversitJ~ of New South Wales, Kensington, New South Wales, Australia

Abstract-Many sources indicate that nurses have a negative view of work with ageing patients. Wide-spread stereotypes concerning old age no doubt exercise influences in the formation of nurses’ attitudes. The research reported here suggests that nurses’ negative attitudes towards the elderly are consolidated rather than dissolved in the course of their training. The reasons for this may not, in fact, lie in the nature of the gerontology components (small as they usually are) of the curriculum. Rather, the course (or the “professional socialisation” process) as a whole appears to carry messages that devalue personal care duties- contra the prestige of activities attached to all levels of medical technology. The ageing patient, often requiring much hands-on (the body) care is thus located well outside areas of work which are perceived by nurses to include clearly focused professional pathways.

Introduction

A considerable number of studies suggest that nurses hold negative attitudes towards geriatric nursing and other work with the elderly. The relevant literature can be traced back to at least the 1950s (for a representative selection, see Tuckman and Lorge, 1953; Kogan,

*An earlier version of this paper was presented at the Australian Sociological Association Annual Conference held at Macquarie University in December 1993.

233

234 J. STEVENS and M. CROUCH

1961; Hickey and Kalish, 1968; DeLora and Moses, 1969; Campbell, 1971; Gunter, 1971; Palmore, 1980; Gomez et al., 1985; Fielding, 1986; Isaacs and Bearison, 1986; Merhige- Winger and Smyth-Staruch, 1986; Brower, 1985; Dewitt, 1988; Philipose et al., 1991); relatively recent studies in Australia (Coulon, 1985; Melanson and Downe-Wambolt, 1985; Palmer and Short, 1989; Gibb, 1990; Gething, 1991; and Stevens and Crouch, 1992) have led to the same conclusion.

Nurses’ attitudes towards work with the elderly no doubt reflect, at least in part, the widespread negative stereotype of old age in society generally (Gibb, 1990) as nurses are social beings and can therefore not be immune to influences from prevailing views. However, one would expect, on the face of it, that professional education might militate against such constructions on the part of trained health care workers. That this is not necessarily the case is borne out by the low level of interest in specialist geriatric training throughout the industrialised world on the part of the medical profession (Sax, 1990). In Australia, for example, in 1992 there were only 35 registrars in gerontology (Davis and George, 1993); and two-thirds of the basic nursing programs across the country devote only 5% or less of their total theoretical program content to issues concerned with aged care (Battersby et al., 1992). Recent research has also indicated that nurses’ attitudes in relation to working with the elderly do not improve, and perhaps even worsen, during the course of their formal education (Stevens and Crouch, 1992).

At the same time, it is probable that there will be an increase in demand for heath care personnel to work in the care of the aged. There are, of course, demographic factors involved; extrapolating from recent figures, various projections for the 21st century all imply an increased demand by those aged 65+ for services of health professionals (for a review of Australian material, see Stevens and Crouch, 1992). However “vertical” restruc- turing and integration of health-care services (Palmer and Short, 1989) and changed public perceptions of health-care needs (i.e. greater expectations regarding fitness and well-being) (Sax, 1990) may also contribute to this trend. In Australia, for example, it has been estimated that the demand for nurses will be approximately 10,000 Registered Nurses for the period 1991l2001 (Manning et al., 1990) this figure being additional to those nurses who will work with the aged in acute hospital settings.

It is by now common knowledge that the population of Australia (and everywhere else in the industrialised world) is “greying”. It is also widely believed that the “baby boom” cohorts will become the most economically burdensome generation of the industrialised world (for example, Rowland, 1991) though not all commentators associate this trend with increased health-care expenditure. Sax (1990) does not foresee a necessarily greater (than presently) utilisation of health services by the elderly, finding evidence in Australian figures for the “compression of morbidity” hypothesis, one implication of which is that the elderly of the future may have better health than their present counterparts (except for the last year or two before death). Surveying a number of Australian and overseas studies, Sax contends that population ageing per se need not cause disturbing rises in costs for medical services-although the present trend of disproportionate use of hospital beds by the elderly will continue.

Nevertheless, given that by 2001 it is expected that nearly 12% of Australia’s population will be in the 65+ age-group (Davis and George, 1993) with nearly half of these in the “frail aged” (75 and over) age-group (Manning et al., 1990) it is likely that the demand for services in this area will rise, especially for paramedical staff, as one of the probable ways in which the cost of the increase in services can be rendered less “disturbing” (Sax, 1990) is

WHO CARES ABOUT CARE IN NURSING EDUCATION? 235

through “casemix” budgetary units employing more nurses who can work autonomously and who can, due to their now comprehensive training, “cover the services previously provided by a variety of different professions” (Franklin, 1993, p. 7). Coupled with recent policy trends towards the provision of a continuum of community care for the elderly (Palmer and Short, 1989) which integrate “vertically” a number of traditional services with community-based facilities (including community and domiciliary nurses), these con- siderations suggest strongly that the next two decades will bring about increasing needs for Registered Nurses in the area of aged care, not only in hospitals but also other structures and organisations in the community.

The nursing profession and the aged have always been linked in both practice and public perception. Contemporary social imagery associates the decline due to the ageing process with some form of nursing care, either at home, with visits by the community nurse, or preceding, in most cases, terminal disability and death in hospital or a nursing home (Sax, 1990; McCallum, 1990; Kendig and McCallum, 1990) although this picture may, in fact, be at variance to some extent with the reality of the preponderance of the “healthy elderly” among the aged population (Job, 1984). Be that as it may, the health services that are eventually required in this area will be expected to be most strongly linked with the nursing profession.

The quality of this relationship between the elderly and the profession has been prejudiced by nurses’ negative attitudes (Gibb, 1990) to aged care. As a result, the profession may be on the verge of losing (perhaps to poorly trained “carers” of one kind or another) its major role in this area-and, more importantly perhaps, the quality of the care for old people in need may be severely compromised. Presently, nurses’ view of this issue appears to be closely associated with increasing “scientification” and “technification” of nursing (Elzinga, 1990, p. 155). An English study (Baker, 1978) of nurses’ attitudes towards working with old people shows that the care of the heavily dependent patient, whose health problems stimulated little medical interest, is perceived as having low status. The value accorded by nurses to their various activities, according to Baker, is directly related to the closeness of the approximation of a nursing task to that of a doctor. A number of writers have observed a similar situation in Australia (e.g. Short et al., 1992; Lawler, 1991) suggesting that “professionalisation” for nurses appears to focus on the acquisition of scientific and technological expertise.

The distinction between “basic” and “technical” nursing (Goddard cited in Lawler, 1991, p. 30) is relevant here. “Basic” nursing is associated with the physical needs of the patient, whatever the nature of her/his illness. On the other hand, “technical” nursing is determined by the disease process and the medical interventions that follow. It is the “basic” nursing in Goddard’s sense that can be seen as the essence of traditional nursing-yet it is “technical” nursing which now carries higher status. Lawler (1991) suggests that this is because “basic nursing” can be seen to imply “a lack of skill and importance” (p. 62) adding that “(T)here has been a tendency within the nursing profession to confuse their concept of hierarchy of nursing skills with the notion of basic and technical nursing” (ditto).

The research

The distinction between basic and technical nursing seems to be the fundamental dimen- sion along which nurses’ responses to work with the elderly are distributed, according to the findings of the study reported here. This investigation represents the results of a three-


year longitudinal study into undergraduate student nurses’ attitudes towards a career in the care of the aged. The research surveys a cohort of students in five schools of nursing in Australia in a repeated measures design study over a three-year period.

A questionnaire was completed by 610 students on entry to the course, 408 at the midway point and 283 just prior to completion of their nursing course. Natural attrition, some administrative errors and failure of many students to identify themselves resulted in a total of 156 matching responses being obtained for the three years.

Participating Schools of Nursing had allowed the questionnaire to be administered during lecture times when it was likely to access the maximum number of students. The instrument was designed to be as unobtrusive as possible. It was decided to rule out the use of more established attitude instruments such as Tuckman and Lorge’s Attitude Toward Old People Scale (1953) because they were too time-consuming. Therefore a short simple instrument was designed specifically for this project. The instrument consists of a ranking task request- ing respondents to place ten nursing specialties in their order of preference; in addition, there is a number of open-ended items which elicit qualitative comments in relation to the rankings. A non-parametric test was used to asses difference among ranks over the three years (Wilcoxon Signed Ranks Test). These results are shown in Table 1 below.

The listing of specialties in Table 1 is arranged according to their rank-order produced by the responses of First Year students. Second and Third Year figures are presented in relation to First Year rankings. The ranks as they appear on the Table are based on the mean ranking for each specialty (in each year) and are intended for descriptive purposes only. The tests of significance are based on individual rankings made by subjects in each year and relate to changes over time for each specialty.

By inspection alone, it can be seen that, overall, the specialties that can be characterised as more “technical” have been rated highly in each year, and, conversely, that the more “basic” nursing areas have been given lower positions.

While there is a number of significant changes in rank positions over the three years, the two most notable are: (1) the raised ranking of “Surgical Ward” and the lowered rank of “Elderly” and “Intensive Care ” immediately after the First Year; and (2) the decline of “Operating Theatre” and rise in “Community Health” and “Community Mental Health” after the Second Year. An impressionistic interpretation of this pattern might be that the sharp line between “technical” and “basic” nursing (and notions of their respective worth)

Table 1. Rank order and mean ranks for career choices of First, Second and Third Year students

Kids’ Intensive care’ Operating theatres’ Surgical ward’ Medical ward Community health Elderly Develop disability Psychiatric nursing Community mental/

health

First Year Second Year Third Year Rank Mean Rank Mean Rank Mean

I 3.42 2 4.24 2 4.44 2 4.06 4 4.36 4 4.13 3 4.20 3 4.28 6 4.90 4 4.49 1 3.85 1 3.19 5 4.50 5 5.00 5 4.67 6 5.50 6 4.99 3 4.35 7 6.62 10 1.64 9 7.03 8 6.93 7 6.81 10 1.42 9 7.60 8 6.88 7 6.81

10 7.6 9 7.00 8 6.83

‘Significant changes between ranks alpha <O.Ol.

WHO CARES ABOUT CARE IN NURSING EDUCATION’ 231

in the eyes of neophyte students could be dissolved to a small degree in the course of further training--except for the perception of “working with the elderly”.

Figure 1 below presents more detailed information regarding this category. The most striking feature of Fig. 1 is the mode-the lowest rank for all three years. More

notable, perhaps-as well as disquietening-is the increase in size of the mode from stage 1 to stage II; while there is a decrease between stages II and III, the size of the mode in stage III remains greater than that in stage I.

The analysis of open-ended questions may throw some light on these results. The reasons given by students for rating “working with the elderly” tenth were coded into four categories and arranged by years as follows:

First Year students

A. negative view of the elderly and type of work 65%, B. negative effect on self-esteem 24%, C. negative effect on career pathway 6%, D. negative experience during the course 0 (rounded figures).

Many respondents in this group focus their negative reactions on the elderly themselves (e.g. “they are depressing”, “they are obsessed with dying”, “they are dirty”, “old people frighten me”). Some also point to working circumstances and the desire for more “exciting” nursing duties. The work with elderly patients is judged to be “frustrating, you never achieve anything”, “dirty”, “futile” and with “a low cure rate”.

Responses categorised in the self-esteem category concern the possible effects of “working with the elderly” on nurses’ personal experience of work. Some typical comments are: “It just would not suit my personality.” “It would depress me.” “I am scared of growing old and 1 don’t like to be reminded of it each day I go to work”.

1 2 3 5 6 I 8 9

Fig. 1. Frequencies of First, Second and Third Year students’ rank for “working with the elderly”.


Second Year students

A. negative view of the elderly and type of work 45%, B. negative effect on self-esteem 44%, C. negative effect on career pathway 5%, D. negative experience during the course 5% (rounded figures).

In general, the reasons given for the ratings were similar to those at the neophyte stage. However, those students who stated that they had a negative experience with the elderly during their practicum also added that they would “never consider working with the elderly” as a career option because of that experience.

Third Year students

A. negative view of the elderly and type of work 49%, B. negative effect on self-esteem 30%, C. negative effect on career pathway 5%, D. negative experience during the course 10% (rounded figures).

Here responses of the group in Category A (“negative view of the elderly and type of work”) are typically represented by statements such as: “Caring for someone who has a better chance of recovery is much more satisfying”, and “I still cannot stand old people”. “No hope-slow death”; “ I do not enjoy working with old people primarily because you work at such a slow pace and you tend to concentrate your skills around basic body care and diversional therapy. ” “I am not interested in this area of work as I feel I may learn more in other acute nursing areas. ” “For the most part its not technical enough.” It is important to note here that responses in this category do in fact bear on nurses’ views regarding the status of their work, even though the contents of the communications may not explicitly be connected with individual career prospects as such.

Reasons that fall into self-esteem and career categories remained similar throughout the three surveys. The category of “negative experience during the course” drew responses such as: “Elderly, aged care is rammed down our throats at Uni, enough is enough.” “I experienced a nursing home on prac and as far as I am concerned it is a slave’s job.” “Most people suffer some form of dementia and are too taxing on one’s patience (sic).”

Discussion

A negative perception of the elderly and work associated with them is the most prevalent reason given for the bottom ranking allotted to specialisation in this area. However, there has been a drop of 20% to stage II and 16% to stage III in this category after stage I and a corresponding rise in Category B (effect on self-esteem), somewhat confabulated by Category D (“negative experience in the course”) figures that apply to stages II and III only.

There is, then, with the more senior and experienced students, a link between the perceived negative effects of work with the elderly and nursing training. By contrast, all students who rated “working with the elderly” most highly as a post-graduation career prospect (5% in stage I, 3% in stage II and 5% in stage III) expressed, in their comments, positive regard for older people in general and gave that as the main reason for the top ranking. This view


appears to flow from a broad moral and ethical position and may therefore be unrelated to professional issues and the effects of training.

The implication of these findings is that processes within nursing education help dis- courage students from considering aged care as a career option. Broadly speaking, such an interpretation is consistent with the contention that currently the “technical” orientation dominates professional concerns in nursing at the expense of the “basic” perspective. The quantitative data from this study also support such a view: with the exception of the category “working with children”, the results for all three stages show that students have ranked “technical” areas more highly than areas requiring largely “basic” nursing work, and that this general ordering holds despite certain mollifying changes over time.

The underlying dichotomy here seems to be between technical proficiency with apparatus (broadly defined) coupled with managerial skills on the one hand, and, on the other, attending to people in various ways. The latter may involve as much skill and require as much knowledge and experience as the former; nevertheless, our student nurses’ training does not appear to be conveying many positive messages about areas of work where caring activities predominate.

On the face of it, such an attitude contradicts texts of “nursing theory” which emphasise explicitly that practices of nursing must, in essence, be caring and “holistic”. We find, however, that this principle is generally illustrated through examples of nursing work which are drawn mainly from areas where expertise with technology is required, such as intensive care and surgery (see for example Orem, 1980; Andrews and Roy, 1986; Newman, 1979, Watson, 1988). Thus, by implication, the message is conveyed that these are the situations that are professionally most demanding and where nurses’ knowledge, skills, discrimination and care are most needed. In turn, the impression arises that “care” and the “holistic approach” are attitudinal factors to be developed to inform, improve and humanise nursing practices and skills, as well as to convey an idealised picture of the nursing persona. As Elzinga puts it, the “holistic perspective and attention to quality of life. . . (assume). . an ideological role” (Elzinga, 1990, p. 1.57). The caring stance “is now grafted onto a scientific core with the help of a philosophical discourse and the incorporation of humanistic studies” (ibid.) and is therefore something other than, something “contextual” to, the (scientific and technological) nursing practices and skills in themselves. In Bourdieu’s terms, the “pedagogic work” (Cicourel, 1993) done to embed student nurses in their appropriate “habitus” defines technological/scientific expertise as the most significant “symbolic capital” of the profession.

Specialist, scientific knowledge and technological competence in health care are associated, in general, with curing-or, at least, the intention to cure-which has been the domain of the authoritative and autonomous medical profession (Freidson, 1980),* while caring has traditionally been seen as the essence of (the calling of) nursing. Presently caring appears to be threatened by the nature of the tasks associated with curing and their technological demands (Watson, 1979). Since Florence Nightingale and the development of modern nursing, the vocational niche of nurses has been in the art of caring. Yet rather than promoting caring as an unique set of practice around which to build a professional image, nurses have tried to raise their occupational status by aligning their praxis to technology

*The medical profession is probably still seen primarily in terms of its carefully cultivated image of control over biologically determined illness (Freidson, 1970), though alternative positions have been put forward (for example, Cassell, 1975).

240 .I. STEVENS and M. CROUCH

and the aims of the “medical model” of curing “conditions’‘-or at least managing them to objectified specifications-through intervention and manipulation. The reasons for this are located in a complex dynamic of practical and ideological variables.

Perhaps the institutional context of modern health care needs to be considered first. In Australia, as in other industrialised countries, health care has become increasingly specialised. The specialties have developed and grown in response to technological and social reforms and innovations that have greatly affected the treatment regimes of patients. Specialist units and hospitals for intensive care, spinal injuries, acute surgical, paediatric and neonatal intensive treatment and care have been established to meet specific needs of particular disease management strategies; thus intensified training and specialised experience are increasingly required by nurses who work in these more “technical” areas. The new drive for recognition, better pay and “professionalisation”,* has been nurtured by these circumstances. It is therefore not surprising that increasingly nurses have come to value them rather more than conditions that may continue to identify nursing with its erstwhile “caring” role.

This role, in any case, has more often than not been associated with sympathetic and nurturing femininity that may have suggested some innate set of predilections rather than acquired competence. Furthermore, it is in this area of “women’s labour” (Rose, 1986) that the subservience of “caring” to “curing”, and of nurses to doctors, has most clearly been identified as a replication of the dominance-submission male-female relationships in society generally (Ashley, 1976). In this view, caring does not benefit only the patients; more importantly for the health-care system and its hierarchical arrangements, it facilitates, by suitably monitoring and preparing the patients, the “real” tasks of medicine that are carried out by the doctors (Leeson and Gray, 1978). This perception has given rise to the need for nurses to distance themselves from caring as a central activity of an occupation now on the “professionalisation” trajectory.

Acquired competence, specialist knowledge and monopoly over tasks central to the application of that knowledge have always characterised the top profession in health care (Freidson, 1970). Therefore, understandably enough, nurses aspiring to professional status have focused their attention on activities in relation to which they too may claim expertise and specifically defined responsibilities, as well as-most importantly, perhaps-autonomy and independent control over their work. With the model of the medical profession and its epistemological power base constantly before them, nurses have sought to be defined as professionals through knowledge and competence, demonstrable in terms of criteria already established at the top of the health-care occupational hierarchy. By contrast, the various aspects of “body work” and “sentimental work” (Seymour, 1989) that largely make up “caring” are much less easily categorised and identified in the rationalised manner that is commensurable with evaluative procedures on which advancement largely depends in contemporary professional settings.

“Caring” is disadvantaged in another important respect. Many “caring” activities are odious; and tending to the body-or some more or less malfunctioning and disturbed minds-is not as clean, clear-cut or immediately challenging as operating intricate equip-

* These developments are embedded in complex socio-economic circumstances, a discussion of which is beyond the scope of this paper.


ment or monitoring complex biochemical therapeutic regimes.7 If ‘caring’ is viewed as a broad philosophy promoting a holistic and considerate perception of the patient in the context of nursing skills otherwise defined (implicitly or explicitly), then “caring” in itself need not be based on knowledge and, therefore, if practiced largely for itself, may be seen only as unpleasant and therefore undesirable. But, as anyone who has worked extensively in a geriatric setting knows, caring is not merely an enabling stance; it consists, in fact, of a complex set of skills such as recognising symptoms, signs and needs, intellectual and perceptual vigilance, theoretical knowledge of conditions with which one is likely to be confronted in a particular setting, the ability to make decisions regarding appropriate strategies to meet needs and alleviate symptoms, the capacity to evaluate and modify action. These are all high-level professional capabilities and require intelligence, training and experience for their full development.

Pedagogic work in nursing education needs to place emphasis on such matters. Within the professional discourse, a case is, in fact, being put for caring in relation to the very same quest for autonomy that appears to undermine it in practice. As Reverby (1989) has pointed out, nurses can develop a new political understanding for the basis of caring, one that “stresses individual discretion and values and acknowledges that the nurses’ right to care should be given equal consideration with the physician’s right to cure” (p. 481)+ provided that nurses also have the political power to implement a policy which recognises their special skills. This position is echoed by Palmer and Short (1989): “If and when nurses take a more prominent role in all levels of health care decision making it is possible that a different type of health care will emerge. It is likely, for example, that nurses will give higher priority to extended care than their colleagues in the medical profession” (p. 145).$ In other words, a genuine division of labour between nurses and doctors will promote the caring skills of the former, but only if such differentiation is, at the same time, a basis for autonomy and prestige of the nursing profession. In the face of the all too attractive lure of technology perceived as the source of expertise and power, the professional and practical value of caring skills has to be actively promoted. This paper indicates that in nursing education the need for action at this level may indeed be acute.

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(Received 19 May 1994; accepted in revised form 6 December 1994)

who cares about care in nursing education?

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