EDUCATION KEYWORDS Continuing professional education / Student status / Perioperative nursing Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication October 2012.

Perioperative nurses’ experiences as students:

the perceived status of being at university by Susan Tame Correspondence address: Aire Building, University of Hull, Cottingham Road, Hull, HU6 7RX. Email: [email protected]

Literature relating to student experience during post-registration education is limited, and focuses on the outcome of the education rather than on the perspectives of the practitioner about what it is like to be a student. This paper illustrates perceptions of 23 perioperative nurses (the participants) with respect to their experiences as students during continuing professional education. Interviews indicated that, whilst study could be stressful, all the nurses enjoyed their educational experiences. Possession of a university student identification card was perceived as symbolic of raised social status. Introduction Governmental and professional body drivers (DH 2008, 2010, 2011, NMC 2011) emphasise the importance of continued learning to enhance patient care. Continuing professional development (CPD) is concerned with acquiring, enhancing and maintaining nursing skills and knowledge, and is a requirement of re-registration (NMC 2011). CPD may incorporate informal and formal learning: it is formal, university-based study, also termed continuing professional education (CPE), on which this paper focuses. Ryan (2003) argued that university-based pre-registration nurse education fosters an intrinsic desire in students to study post-registration, to allow personal and professional growth. However, whilst this may encourage recently qualified nurses to study, those who qualified prior to integration of nursing to higher education may not find CPD easy to embrace (Gopee 2001). The National Institute of Adult Continuing Education (NIACE 2004) states that societal attitudes have changed following government initiatives which assume that people wish to learn (DfEE 1997a,b, 1998) resulting in increased participation in lifelong learning. However, Titmus (1999) asserts that social and cultural factors influence whether learning is undertaken. As such, it could be assumed the context and social system in which nurses live and work influences attitudes towards CPE (Ellis & Nolan 2005). This

paper argues that, despite associated challenges, perioperative nurses enjoy their experiences as post-registration university students.

Literature review It is claimed that education transforms lives (Heaney 2000), and CPE is enjoyable, stimulating, and to be recommended (Sheperd 1995). However, the extent of a nurse’s desire to learn determines the amount and kind of education undertaken (Gopee 2003), with previous experiences of education, along with the profession and culture in which they are situated, influencing access to higher education (Gopee 2003, Stanley 2003, Ellis & Nolan 2005, Tame 2009). The integration of nurse education into universities appears significant, as some students have indicated that if educational experiences create an impression that learning is about passing or failing, not about professional development, this may deter access to CPE (Nolan et al 2000, Ryan 2003). On a more practical level, Gopee (2003) found that nurses are deterred from formal study because it is a new concept; he also described its ‘continuing’ nature as daunting, overwhelming some professionals. Such attitudes may be changing however, as some nurses appear to access many formal study opportunities (Nolan et al 2000, Tame 2009). The literature indicates that participation in formal study relates to personal reasons,

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including increased confidence, as well as having family, friends and peers who are studying or are well educated and supportive (Schuller 2000, Gopee 2003). Alternatively, study may be undertaken to increase motivation, morale and job satisfaction (Nolan et al 2000, Barriball 2002, Cooley 2008), and improve career prospects (Nolan et al 2000, Hardwick & Jordan 2002, Barriball 2002, Gopee 2003, Stanley 2003). Other reasons for accessing CPE include maintenance and development of competence, knowledge, and skills (Smith & Topping 2001, Hardwick & Jordan 2002, Ryan 2003, Cooley 2008). Dowswell et al (1998) reported that nurses, midwives and allied health professionals may study due to negative feelings about themselves or their professional status, or negative changes to home situations. Nolan et al (2000) acknowledged that respite from work during CPE allowed reflection on nursing practice, increased nurses’ motivation and self-actualisation, and created a desire to pursue additional education. Whilst Smith and Topping (2001) described personal changes from CPE as ‘value-added’ benefits, for some nurses these provide the primary motivation to study (Nolan et al 2000). Thus, the effects of student status and resultant personal outcomes, rather than professional motives, may be motivators for nurses’ study. Although individuals may benefit personally from CPE, barriers exist prior to and during



Perioperative nurses’ experiences as students: the perceived status of being at university Continued

formal study. Gopee (2002) described that individuals are required to invest time, mental and financial resources into study. Challenges may also relate to home and domestic responsibilities, particularly with regard childcare (Dowswell et al 2000, Gould et al 2007). As formal study impacts on nurses’ home lives in relation to traditional female roles (Cooley 2008, Schweitzer & Krassa 2010) support from family members is imperative, as there is often reliance on relatives for childcare (Cooley 2008). Whilst single parent families may be particularly affected (Gopee 2002), if partners are not also studying, personal relationships can be negatively affected due to a widening divergence of interests and feelings of inadequacy (Dowswell et al 1998, Gopee 2002). Nurses may also experience guilt when CPE removes them from family activities (Dowswell et al 2000, Gopee 2003, Stanley 2003, Cooley 2008). The literature illustrates the fact that multiple factors influence CPE, however it does not fully explore nurses’ feelings and experiences as they progress through formal study, or describe why some nurses continually access formal study despite significant barriers relating to their studies. In addition, transferability to perioperative nurses may be limited due to the influence of gender and complex inter-professional relationships in this paternalistic environment (Carter 1994, Coe & Gould 2007, Collin et al 2011). As such, there was a need to investigate the perceptions of perioperative nurses with regard to their experiences as students undertaking university education.

Methodology Participants A non-probability, purposive sample of perioperative nurses employed within one large teaching NHS trust was chosen. Letters of invitation and information sheets were distributed to nurses who, according to a local database, were currently undertaking CPE or who had studied within the last three months. Similar letters and information sheets were sent to nurses who appeared never to have accessed university courses. These letters were sent in batches of ten to ensure that participants were not waiting for interviews for longer than three months. Each potential participant was


given four weeks in which to express their interest in participating.

Data collection Data were collected through in-depth, unstructured individual face-to-face interviews, conducted at participants’ convenience in private rooms in the workplace. The pace and length of interviews were determined by participants, and lasted between 40 and 90 minutes. The topic guides used to provide parity between interviews were flexible, and incorporated new topics as these emerged, for use with subsequent participants. Participants were encouraged to illustrate their experiences using examples, enabling a deeper understanding of CPE.

Data analysis Audiotapes were transcribed verbatim into the Ethnograph as soon as possible following an interview. The familiarity required for constant comparative analysis (Strauss & Corbin 1998) occurred through reading and re-reading transcripts prior to annotating each phrase, sentence or paragraph with a code or codes which arose from the data (Dey 1993). Similar codes were clustered to create subcategories and categories where relationships existed, and categories were grouped into themes, allowing a picture of CPE to gradually emerge. Codes, sub-categories and categories and themes were split (subdivided) and spliced (merged) to ensure that they remained inclusive, exclusive and exhaustive of data (Dey 1993, Seidel 1998). Once coded, a précis of each interview was written detailing its contents, and upon data saturation, paragraphs were written about each category and theme. Constant comparative analysis allowed understanding of experiences within and between interviews, and enabled identification of similarities and differences (Seidel 1998, Strauss & Corbin 1998). Thus, data were summarised with the emergent themes describing not only individual categories, but cutting across categories weaving the analysis together, to allow understanding of student experiences.

Ethical considerations Ethical permission was granted by the Local Research Ethics Committee (LREC)

and the NHS trust in which data collection took place. Participants were fully informed of the study, and how the data would be anonymised, prior to consent, and were aware that they could withdraw at any time. On completion, all participants received a summary of the findings.

Rigour Data collection continued to saturation; since participants represented different grades and departments, this indicated sufficiency (Seidman 2006). Interviewing only nurses with recent experiences of study allowed these, not retrospective accounts of CPE, to be explored. The use of the Ethnograph aided trustworthiness by allowing all instances of codes to be located and understood within their original context. Constant comparative analysis enhanced credibility through flexibility in coding and analysis of data. Discussion of emergent categories with participants provided alternative perspectives on emerging themes.

Findings Data collection took place over 11 months, between February 2006 and January 2007. Twenty three female nurses were interviewed who had between 2½ and 30 years’ experience, with between 2½ and 25 years in perioperative care. It was not possible to recruit nurses who appeared never to have accessed CPE. Participants were studying a range of theoretical and practical subjects, including mentorship, advanced scrub practitioner and evidence based practice modules. They all spoke enthusiastically of their time as students, describing their experiences as ‘enjoyable’ and exciting’. Most explained that their enjoyment began prior to the course and continued throughout, despite the stresses and sacrifices associated with the impact of their study on themselves and their families. In addition, CPE appeared to dominate participants’ thoughts: It’s always at the back of your mind [Participant 3, team leader] You have to be very careful with university courses. … I think you get obsessed with them in a way, and … you don’t have the time or energy to do stuff … at work. … [T]

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The role of student appeared to hold more status than, and provide departure from the routine of the traditional female roles of nurse and housewife

here’s only so much your brain can take at once [Participant 10, team leader]

family and you’ve just got to plan it that way [Participant 7, matron]

Whilst the impact of CPE was felt at work, it appeared to have a greater impact on participants’ home lives, and necessitated temporary sacrifices and shifts in priorities, as has been reported elsewhere (Stanley 2003, Ellis & Nolan 2005, Cooley 2008). These sacrifices appeared to relate to the competing demands of participants’ roles as mother or carer, partner or wife, nurse and student:

Although courses were seen as discrete units of time, after which other activities could be resumed, participants continued to study, despite the stresses and sacrifices incurred. It appeared that this decision was made due to enjoyment derived from physically attending university, undertaking academic activities, and the opportunities and resources made available by virtue of their student status:

It’s all very well to … say … ‘I’ve drawn up my plan and this is when I’m going to study … ‘ It doesn’t happen like that [Participant 8, perioperative practitioner]

A huge range of resources … has been opened up. … It’s really nice to … be a student and … have those resources [Participant 8, perioperative practitioner]

When you’ve got a family and … housework to do and … coming to work full time … it was a bit of a nightmare [Participant 10, team leader]

Getting your books … bringing them home and flicking through them … [is] probably the nicest part of doing any course! I think what it is, is the possibilities of learning more [Participant 10, team leader]

As previously documented (Dowswell et al 2000, Tennant & Field 2004, Cooley 2008), multiple demands created additional stress and guilt, and left participants unable to relax or socialise: You’re watching telly thinking … ‘I shouldn’t … be doing this, I should be reading that chapter’ [Participant 13, team leader] My husband … thought ‘shall we go away for the weekend?’, and I said ‘… I can’t go … because I need to spend the time doing assignments’ [Participant 21, perioperative practitioner] We used to … visit ... friends … but … I can’t … until this essay is finished’ [Participant 23, senior practitioner] The all-consuming nature of CPE and the consequent stress and guilt have been reported previously (Stanley 2003, Cooley 2008). However, some participants appeared to achieve more of a work-life balance: Time that I would have spent reading, I’m [studying] … which isn’t a great sacrifice ’cos it’s only for 12 weeks [Participant 2, senior practitioner] Out of so many weekends … you’ve definitely [got] to … do something with your

I look forwards to … writing an assignment! … I just enjoy sitting down, reading … putting down your thoughts, and … hopefully get a good result [Participant 21, perioperative practitioner] Whilst participants attributed access to such resources as being due to their student status, the resources could also be accessed as trust employees, which suggests that their feelings and enjoyment resulted from something other than access to educational resources. For many participants this appeared to relate to possession of a student card: There is that little sort of like oh, well … I’m a student. You get a student card and you … think ‘yeah, I can do this’ [Participant 19, senior practitioner] The student card appeared to be symbolic of acceptance into a perceived elite group, and to represent external confidence in their academic ability. Possession of a student card appeared to change participants’ selfperceptions, as well as to provide practical benefits: I felt quite young! I … sort of felt equal … to my son [Participant 8, perioperative practitioner]

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My children … were signing up for student discount, and … said to me ‘… get your student card out’ [Participant 15, perioperative practitioner] They did ask us ‘are you students?’ … So we got some discount [Participant 23, senior practitioner] As with access to resources, similar discounts were on offer through participants’ NHS employment, however, they described using student cards rather than NHS identity cards to receive discounts. Obtaining student discount publicly displayed participants’ status and acceptance into university, raising their status from ‘nurse’ to ‘university student’. This suggests that attending university was perceived as more than just an opportunity to learn, and participants’ excitement appeared to be rooted in their transition from ‘nurse’ to ‘student’: Somebody going off to university and bettering themselves [Participant 19, senior practitioner] Its just got a bit of a status thing … that you’re at uni. … That you are … doing things - active, in your life … not just … cooking, washing, cleaning. You are … using your brain, doing a bit more [Participant 21, perioperative practitioner] The role of student appeared to hold more status than, and provide departure from the routine of the traditional female roles of nurse and housewife. For participants conditioned to believe that they were not academically able to enter higher education, challenging this perception may be the source of such excitement. Through using their student card they were able to reveal their student status to others, which illuminated their achievements and perceived elevated status. Although participants enjoyed their student status, this was seen as a temporary existence: It’s … like a different culture that you’re dipping into, and then it’s back to reality … back to working in PACU [Post-Anaesthetic Care Unit] [Participant 19, senior practitioner]



Perioperative nurses’ experiences as students: the perceived status of being at university Continued

Whilst work roles were resumed, participants often spoke of their desire to re-enter CPE, despite the stresses encountered. This suggests that for participants the sacrifices and challenges presented by formal study are outweighed by their status as university students.

Discussion Limitations Participants may repeat what others have told them during interviews, or may give responses they think the researcher wishes to hear. Or they may play antagonist. NHS initiatives which raise the profile of health professional education may have influenced participants’ descriptions. Precautions were taken to avoid disruptions, however, some interviews were interrupted which may have affected the data collected. Interviews were conducted six years ago as a part of a doctoral study, and changes within nursing and higher education in the interim may have altered nurses’ experiences and perceptions of student status.

Participants’ experiences as students All participants spoke positively of their experiences even though balancing the demands of study with work and domestic responsibilities led to stress and left little time for relaxation (Dowswell et al 2000, Tennant & Field 2004, Evans et al 2007, Cooley 2008). Participants’ emotions and experiences in terms of adapting to student status can be related to Shane’s (1980) ‘returning to school’ syndrome; initially participants were excited about studying and its new experiences and were in the ‘honeymoon’ phase. This was then replaced by a period of ‘conflict’ where participants experienced competing demands at home. However despite these demands, participants continued with further study: This suggests that they had reached the stage of the ‘biculturalism’ (Shane 1980) where they were as comfortable in university as in work. That is, if participants had previously studied, they were more likely to study in future, in spite of the stresses and sacrifices, for existential gains and the ability to refer to themselves as students. Kierkegaard (cited in Rocca et al 2011) saw realisation of personal potential as the meaning of existence, and participants also emphasised the


importance of attending successively higher courses in order to achieve their academic potential. In addition to providing access to resources, student status seemed to change participants’ self-perceptions, and was symbolised through possession of student cards. Whilst no literature illustrating the concept of student cards could be located, all participants described these as significant and part of the excitement experienced during the ‘honeymoon’ phase of study (Shane 1980). Their public use provided tangible benefits, and using these in preference to NHS identity cards demonstrated participants’ status as students who were ‘bettering’ themselves, and as such their possession may have psychological benefits.

Impact of student status “The cultural narration of nursing is for nurses to be subordinate” (Freshwater 2000 p481) and even in the 21st century, medicine is widely portrayed as being dominant to nursing. This may be due to its emphasis on ‘curing’ and the intellect and skills required, rather than ‘caring’ which is seen as an extension of females’ natural attributes and roles in the home (Hahessy 2007); medical staff in the perioperative department holding more power than nursing staff (Collin et al 2011). Participants’ perceptions indicated that becoming students raised their status from ‘nurse’ to ‘student’. Whilst some studies indicate that nurses study to raise the status of nursing (Ryan 2003, Stanley 2003, Bahn 2007), this was not an explicit motive for participants. However, studying did appear to remove them at least temporarily from female domestic roles, which, as Gopee (2003) described, may be a form of escapism. Stepping out of traditional female roles may contribute to participants’ perceptions they are doing a ‘bit more’ with their lives. In contrast to Bojtor (2003) who asserted that, despite higher education, nurses’ social or occupational status remains unaltered, participants appeared to equate being university students with greater status and kudos than being a nurse or a woman. Student status appeared to allow them to move away from the publicly perceived image of nurses as unintelligent

(Neilson & Lauder 2008) and to verify their intelligence to colleagues, friends and family, in a way perhaps not enabled in the operating theatre due to the complex inter-professional relationships (McGarvey et al 2000, Coe & Gould 2007, Collin et al 2011). This paper extends knowledge relating to perioperative nurses’ experiences as students, and suggests that, despite the sacrifices and stressors, CPE is enjoyed. The possession and public use of student cards appeared particularly important, and may elevate participants’ perceived status from ‘nurse’ to ‘student’. Further work is required to explore the importance of student card possession, and to examine the effects of the perceived elevated status on contemporary perioperative practice.

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About the author Susan Tame PhD, MSc, PGDip, BSc (Hons), PGCE (FE), RN (Adult) Lecturer, University of Hull

No competing interests declared

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Perioperative nurses' experiences as students: the perceived status of being at university.

Literature relating to student experience during post-registration education is limited, and focuses on the outcome of the education rather than on th...
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