Desperately seeking sociology: Nursing student perceptions of sociology on nursing courses

The students 

The research employed a qualitative methodology to explore students’ perceptions of the relevance of sociology to nursing. In both the Diploma in Higher Education (DipHE) programme and the degree programme students are taught sociology as a foundation to their study, which is then expected to be applied throughout the remainder of their study. On the degree programme students receive two sociologically focussed modules within the first 18 months of study. On the diploma programme students receive two modules in their first year covering both sociology and psychology. Participants were drawn from first and third years of each programme. It was felt it would be useful to talk to students early on in their study and therefore relatively close to having studied sociology within the context of nursing, as well as those students more advanced in their nursing study. This group should have some distance from having had direct sociological input, but perhaps with more chance for its application.

Recruitment 

Four focus groups were organised, each with six participants. Two focus groups were drawn from the DipHE, one with first years, the other with third year students, and two from the degree programme, one with first year, the other with third year students. Due to the timing of vacations, we were unable to run the first year degree student focus group. There were, therefore, three focus groups, with a total of 18 students. Students were invited during lectures to take part in the research. They were provided with details of the study, a return-addressed envelope and a consent form to sign. It was made clear that they were under no obligation to take part. Students were offered lunch after the focus group.

The focus groups 

Focus groups were facilitated by a Research Associate to ensure respondents were not influenced by the presence of a member of teaching staff. Particular attention was paid to respondents’ awareness and understanding of the epistemological uncertainty that surrounds social scientific analysis being taught alongside the desire for certainty necessary to safe and efficacious practice. Qualitative focus groups enabled interaction among respondents to facilitate the joint construction of meaning. On the basis that some respondents, as individuals, may have had little in the way of established views on the topic, it was anticipated that focus groups would generate a process whereby respondents are forced to think about and possibly revise their views as meanings get generated (Bryman, 2004). This method allowed respondents to probe each other’s reasons for holding certain views, thereby generating a variety of views.

Ethics 

Ethical approval for the study was granted by the University of Nottingham Medical School Research Ethics Committee. Students were approached in such a way that they had time to consider whether to take part, and did not feel pressured into participating. Written consent was taken at the beginning of the focus group. Students were free to stop the focus group at any point, or to not answer any question. All data were anonymised and stored securely in line with applicable laws and guidance. There was no risk that the focus group would cause any distress to students.

Analysis 

The focus groups were recorded and transcribed. Analysis of the qualitative data used Strauss and Corbin’s (1990) constant comparative method to generate categories, patterns and themes from the textual data. The thematic analysis of the data was developed through an iterative process of reflection, scrutiny of the transcripts and discussion among the researchers. Themes were derived both in vivo, and by a more theoretically driven process of induction.

Trustworthiness 

The issue of establishing the quality of any qualitative study is a complex one, and has been extensively debated (e.g. Mays and Pope 1995), and there is no consensus within the field. We opted to use neither member validation, for the reasons discussed by Bloor (1997), nor triangulation, for the reasons discussed by Silverman, 1985, Silverman, 1993. We have sought to present a detailed (Silverman, 1989, Dingwall, 1992) account of how the study was conducted, which acknowledges the complexity and situatedness of the findings, including ‘negative’ cases (Dingwall 1992). The limitations of this study are acknowledged.

Recalling sociology on the course – a critical perspective? 

The initial recollection of the focus groups of the sociological content on the course was patchy. Few student nurses could remember specific material. There was some mention of concepts such as health and poverty, or, as one student expressed it, “Stereotypes … stereotypes and gender things, nursing, and things like that” (3rd year degree student). Much of what student nurses described as sociological lay within the realms of understanding patients’ backgrounds and could be described as multiculturalism. In other words there was some understanding that an awareness of cultural differences was helpful for shaping their perceptions of the care offered to patients. To this extent while it may be stretching it to suggest that student nurses at this stage in their learning were embodying an emancipatory agenda, they were nevertheless articulating some of the tools that would be necessary to facilitate a critical perspective of the bio-medical model of health and illness.

Fragmented knowledge – time and reflexivity 

The student nurses interviewed experienced a feeling of fragmentation during their early studies. However as training went on, and placement experience accumulated, respondents expressed the notion that disparate ideas learned at an earlier point were coming together in their practice:

Although I didn’t think this way at first. I thought we were given all these random things in lectures and then we got to the ward and I thought, ‘I don’t know how to take advantage of that.’ You know it just seemed so far removed, but actually it is coming together more now as a merger, you know you’re looking more. (3rd year degree student)

It’s becoming more aware of it. And also as the levels have progressed, looking back on our time on placement, I can see a lot more of what they are teaching in retrospect, in hindsight. (3rd year diploma student)

So, from these descriptions, the use of sociological insight in practice comes as part of the experience of practice on placement: “It’s experience you want, but it’s just down to practice and getting the experience”. This accumulated understanding of their studies and its place within nursing practice reflects the literature on nurses’ knowledge acquisition. Heath (1998), in her study of nurses’ practices of knowing, suggests that theory must go along with experience, meeting at moments of reflexivity towards an accumulation of good nursing knowledge. That is to say, the path of theory through to practice needs to be intercepted by experience.

And it’s their teaching [lectures] that’s making thinking move forward, because they are actually saying that [patients] shouldn’t lose your identity when you come into hospital. And that’s simply why they are applying that to practice. As you go through the course, you can actually see why they do that. (3rd year diploma student)

…And you can’t get that within the first year of being here. That’s not going to change. (3rd year degree student)

These quotes indicate that the accumulation of good nursing practice, involves both the theory (in this case the sociologically informed concept of identity) together with reflexivity in practice and that together and over time, knowledge and understanding develops. Students talked of gaining, over the training period, more experience which helps in the appreciation of the application of theory. This materialist perspective, that lived experience informs the superstructure of ideas is Marxist (Williams, 1973) in its interpretation, nevertheless, within the analysis, appears to represent the actual pattern of knowledge acquisition among the students interviewed. This helps us to understand why sociology is a problematic topic for nursing students. The medical model is sufficiently hegemonic (Gramsci, 1987) within society in general (Kleinman, 1980) let alone medical care in particular that sociology without the context does not make much sense to many students. However, once they have acquired more experience in practice, sociology it seems, becomes more meaningful. This is particularly noticeable when students experience practice in the community, rather than through hospital placements, where the medical model is perhaps less dominant in those community settings. This issue of the context of the placement experience is a point to which we shall return. In terms of the relevance of sociology to nursing it seems that a diachronic dimension is especially important to the accrual of understanding. This problem of understanding the relevance of sociology is especially acute for sociology as it is typically taught early on in nursing courses. The following quote from a first year diploma student mentions the tension between the need for clear models of practice (never a straightforward thing in sociology), and the need for practical experience to bolster those models:

Maybe some more of the models and things like that, and the experience that we are going to have in practice. Try out a few models and different things. It’s [the module] still very like more general. (1st year diploma student)

That knowledge was experienced as being fragmented may be as a result of the modular structure of the programmes. Mowforth et al. (2005) do not report this being perceived as a problem with the students that they studied, though they do say that students did encounter difficulties with what they term the ‘integration’ of knowledge, analogous with our findings.

Biology and sociology – hierarchy of knowledge 

By way of contrast, the focus groups were asked if they had drawn any comparisons between biology and sociology. The general feeling was that they were both important but different in their approaches and application. Indeed, the relevance of both subjects in practice was viewed as discrete; in other words it was felt that in practice when the relevance of one finished the relevance of the other took over. When describing critical incidents, sociological insights took a back seat in favour of more biologically driven practical nursing procedures.

Yes, when you are busy. In high dependency patients the focus of your sociological side of things is different. Your clinical skills and your biological things, trying to cure that patient and giving medication and things like that, takes over from your sociological side of things. (3rd year diploma student)

It’s priorities to begin with. We need the life saving priorities in there first don’t we? And then you deal with the social aspect. (1st year diploma student)

This approach of perceiving different forms of knowledge as discrete also clearly lends itself to imposing a hierarchy on knowledge according to context. It could be suggested that this process of imposing a hierarchy onto knowledge types contributes to the difficulty of seeing a patient as a social being when their physical condition is challenging. At its extreme dying patients are known to experience a ‘social death’ before their physical death (Sweeting and Gilhooley 1992).

The view among student nurses was that biology was a fixed subject, in other words that the physiology of the body remains constant. In contrast sociology, because its insights come from the social world, is constantly changing. Similarly, the view was that biology, by and large, was uncontested whereas sociology was burdened by competing perspectives.

I think it changes a lot with sociology, whereas with biology it doesn’t. It’s ground, it’s a fact, and that’s how it works. But to a certain degree, probably generalising it a bit too much, but for a sociological aspect, it changes all the time because society changes. (3rd year diploma student)

It is questionable whether the general belief that sociology is dynamic and non-foundational is formed from a personal or a professional epistemology. Clearly a professional epistemology requires skills and knowledge are grounded in ‘best practice’. Practices, reflecting learnt skills, have to be honed for the purpose of carrying out procedures which on the face of it appear to the novice as requiring clear cut performance. Under these circumstances sociology is viewed as unsettling and possibly therefore as of secondary importance, when the anxiety of student nurses is to be competent, safe and efficacious practitioners. One argument within the literature views nursing as a ‘doing’ job, not a ‘thinking’ activity (Sharp 1995): nurses, developing their role within this framework are more likely therefore to see sociological debate as hindering their perceived role as empirically orientated practitioners. We see these feelings of anxiety expressed in the following statement, where a hierarchy of learning becomes the coping strategy, so that biological sciences become paramount and sociology – although important in effective practice – as secondary. Note the physiological metaphor:

Yes, it’s more important at this stage for us to get a backbone [our emphasis] and then the sociology course, it is important, but we can develop that as we go along, whereas the biological side we really need to have. (3rd year diploma student)

Where being taught sociology could be said to provide student nurses with the tools for a critical perspective towards the bio-medical model of health and illness, the tendency to place a hierarchy upon knowledge appears to reassert the bio-medical model of nurse intervention.

Hierarchy and context 

However, the influence of the hospital environment and the predominant influence of the bio-medical model were not determinant in the perspective of all the student nurses interviewed. Respondents made a connection between the context of their practice and the hierarchy of knowledge. In other words context for practice was a significant factor in determining a student’s reactions to sociology. For those student nurses who had placements in community settings, there was a shift towards a more sociologically informed model of practice. With those nurses experiencing this form of nursing as well as health visitor intervention, the emphasis was on a more sociological understanding of people’s circumstances and needs.

You are dealing with people, not just cells. (3rd year degree student)

Yes, because doctors tend to concentrate more on the biology side and the nurses’ role, it has been perceived in the past to be a care, well it still is a caring role, people say it, but you are aware of the biology stuff, but through your communication you are actually dealing with the psychological issues…how the illness has got there in the first place. (3rd year diploma student)

For some participants, their sociological knowledge was more important than biology in relation to their practice, thus reversing the hierarchy of the bio-medical model.

Sociology is much more practice-based. So much more practical. You are in contact with it from day to day on the ward community wherever you are, whereas biology, you are not really using biology as much, so even though it’s the backbone [our emphasis] of your nursing thinking, it’s not your everyday communication. (3rd year degree student)

and

It’s good to understand the family from the community perspective because you can always understand the patient when he comes in whereas it’s not necessarily teaching you how to apply it. You have to try and make that connection yourself. (3rd year diploma student)

This quote comes from a student who states that her practice interest lies in community nursing. She feels that in terms of practice in the community, sociology had a strong influence on the interventions of the community based nursing team, who according to the student were, she felt, actively interpreting the issues of health and social deprivation as having a sociological root. In contrast, those students who had mainly had placements within the hospital ward setting felt that developing skills in medical treatment and surveillance, for example, performing observations such as blood pressure accurately were skills that would strengthen their effectiveness as nurses. Snelgrove (2004) argues that students with a ‘deep’ learning style had embraced a more sociological way of thinking. While we did not investigate the issue of learning style, it is possible that what is being reported here has some parallels with Snelgrove’s findings.

Risk and practice 

The issue of risk weighed heavily on all the student nurses we interviewed. This was manifested in their desire to gather as much knowledge and experience of particular tasks, which might be viewed as risky in the management of patient health. The students were keen to point out that they wished to get to the position where they were no longer a risk to the patient. According to the students, this would be ensured when they had mastered everyday care skills such as fitting a hydration cannula, or stabilising the patients’ body functions. In general terms, student nurses interviewed expressed the desire for a clearly defined model on which to practice. Uncertainty was a zone of liminality, where unformed ideas struggled to make contact with material reality; where an idea or a theory could be attached to a formal procedure.

We do learn everything obviously, but it feels sort of so mixed up, so it’s hard to define what’s psychology, what’s sociology. Everything’s sort of, nothing’s, it’s not necessarily a bad thing, but I mean, for the purpose of this, you can’t sort of signpost, that was that or that was that. All mixed in together. (1st year diploma student)

For the respondents ‘risk’ is being narrowly interpreted as physical. In other words they are not expressing the view that sensitive sociologically informed communication might also reduce risk for the patient. Clearly for some patients an emancipatory framework of communication may determine their compliance with a regime of care and even the ability of a patient to seek help in the first place.

The space of confusion, embodied by sociological knowledge was accompanied by a high level of anxiety for risk avoidance and the need to displace responsibility by a mechanical process of skills acquirement, rather than having to embrace the complexity of interdisciplinary reflexive practice.

If it was more tailored, that would be more helpful, so you don’t have to think of everything yourself. (3rd year diploma student)

This kind of anxiety among student nurses is hardly a new phenomenon (Menzies, 1960, Melia, 1984, Melia, 1987), but what is significant is that the subjects that they are being taught contribute to their uncertainty and anxiety, rather than reduce it. So while sociology may have played a part in this anxiety (as predicted by some of its detractors), we would want to argue that it is not so much sociology alone, as the whole panoply of subjects and approaches to which students are exposed that give rise to their struggle with knowledge and practice acquisition. Nursing is perhaps an inherently difficult subject precisely because of its interdisciplinary nature. Students had difficulty in seeing how all their studies fitted together (with some justification), as well as seeing how, taken as a whole, they could be related to practice. These difficulties, which could be considered to be epistemological in nature, have strong parallels with those discussed by Knight and Mattick (2006) in their study of medical students’ ways of knowing. These included a desire for certainty in knowledge as a guide to safe clinical practice, and a tendency to move from more simplistic views of these epistemological issues to more sophisticated views over the duration of the course.