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   Table of Contents      
ORIGINAL ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 1  |  Page : 19-25

Exploring the dominant discourse of baccalaureate nursing education in Iran


1 Department of Critical Care, Nursing and Midwifery Faculty, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan; Department of Medical Surgical, Babol University of Medial Sciences, Babol, Iran

Date of Web Publication14-Mar-2017

Correspondence Address:
Sepideh Mohammadi
Student Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Department of Medical Surgical, Babol University of Medical Sciences, Babol
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.IJNMR_239_15

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  Abstract 

Introduction: Understanding how academic dominant discourse is implicated in the shaping of nursing identity, professional aspirations and socialization of nursing students is useful as it can lead to strategies that promote nursing profession. Materials and Methods: This is a qualitative research conducted through discourse analysis approach. Semi-structured interviews, focus group, and direct observation of undergraduate theoretical and clinical courses were used to collect the data. Participants were 71 nursing students, 20 nursing educators, and 5 nursing board staffs from five universities in Iran. Results: Data analysis resulted in the development of four main themes that represent essential discourses of nursing education. The discourses explored are theoretical and scientific nursing, domination of biomedical paradigm, caring as an empty signifier, and more than expected role of research in nursing education discourse. Conclusions: The results indicated that academics attempt to define itself based on “scientific knowledge” and faculties seek to socialize students by emphasizing the scientific/theoretical basis of nursing and research, with the dominance of biomedical discourse. It fails to conceptually grasp the reality of nursing practice, and the result is an untested and impoverished theoretical discourse. The analysis highlights the need for the formation of a strong and new discourse, which contains articulation of signifiers extracted from the nature of the profession.

Keywords: Baccalaureate nursing, discourse analysis, nursing education, nursing student


How to cite this article:
Yazdannik A, Yousefy A, Mohammadi S. Exploring the dominant discourse of baccalaureate nursing education in Iran. Iranian J Nursing Midwifery Res 2017;22:19-25

How to cite this URL:
Yazdannik A, Yousefy A, Mohammadi S. Exploring the dominant discourse of baccalaureate nursing education in Iran. Iranian J Nursing Midwifery Res [serial online] 2017 [cited 2021 Nov 27];22:19-25. Available from: https://www.ijnmrjournal.net/text.asp?2017/22/1/19/202068


  Introduction Top


Today's students are the nurses of tomorrow [1] and nursing faculty plays an important role in constructing learning environments that foster the positive formation of future nurses.[2] Nursing faculty is the primary source of learning professional attitudes and culture of the profession to which students aspire to belong.[3] The students' formation of a nursing identity is grounded in social interactions with faculty and is shaped by values and norms learned by both the formal and informal curriculum.[2],[4]

Understanding how academic dominant discourse is implicated in the shaping of nursing identity, professional aspirations and socialization of nursing students is useful because it can lead to strategies that promote nursing professionalism.[5],[6]


  Literature review: Background in Iran Top


Initial preparation of nurses in Iran is a Bachelor's degree, and the nursing program bears some similarities to the nursing education programs worldwide. The basic nursing programs in Iran offer a four year baccalaureate in nursing which is accredited by the Ministry of Health and Medical Education.[7] The learning environment for students engaged in baccalaureate programs is shared between classroom, hospital, community, and other educational settings.[8] Nursing students start their clinical training from the second semester, and this is run concurrently with theoretical courses until the end of the third year. The fourth year is allocated exclusively to clinical placement training. They learn in the clinical environment under the direct guidance and supervision of a nurse teacher.[9]

Bachelor's degree curriculum is the same in all universities in Iran and has undergone various reforms over the past decades with the intention of ensuring that the knowledge and skills of graduates match requirements for providing high-quality care. The most recent reform started in 2011 and was guided by the following tenets: evidence-based nursing, community-oriented education, competency-based education, problem-based learning, and student-centered education.[10] Despite undeniable progress and many changes in nursing education, faculties have encountered some problems in the process of nursing professionalization,[3] and still nurses' behaviors are based on traditional approaches. In addition, the other products of this approach is training nurses who have less professional apprehension and commitment for participating in professional decisions.[11]

According to an Iranian study, nursing students have numerous problems with their professional identity and they are not proud of being a nurse.[12] The findings of other study in Iran indicate that the nursing students in Iran enter the clinical environment while they have not accepted themselves as nursing students and have no interest in their profession. Many of them do not accept their profession even until the end of their course and moststudents are not adequately prepared to work in the clinical setting.[13] Yousefy et al. (2015) in their study indicated that there was a clear conflict and role ambiguity in Iranian nursing students and educators.[3] In addition, a study conducted by Yazdannik et al. (2012) revealed that senior undergraduate students do not know who they are, why they have entered this profession, and what the values of their profession are.[12] Nursing education problems exist not only in Iran but in other countries also. Scully in her study indicated that matching textbook descriptions of clinical situations with the reality of practice is an ongoing problem faced by members of the nursing profession and is commonly referred to as the “theory-practice gap.” This ubiquitous gap is inevitably encountered by all nursing faculties at various times.[14]

For solving existing problems in nursing education, many of the faculties, educators, and administrative boards in nursing education are interested to know, what is the dominant discourse in the nursing faculty?, what is the product of this discourse ?, what is happening in the academic education environment?, and how do educators and the program socialize students?

Most of the Iranian research studies in this regard were conducted at one faculty by a small number of research participants so as to achieve comprehensive results; we conducted our study in five geographically diverse universities in Iran. It was assumed that the findings of the current study would provide support for nursing faculty in developing, maintaining, and enhancing the quality of nursing education.


  Materials and Methods Top


A qualitative design could increase the understanding of nursing faculties' voices, views, and thoughts.[3],[15] Discourse analysis is concerned with how an individual's experience is socially and historically constructed by discourse.[16] In fact, academic discourse influences how nursing students practice as nurses. Therefore, discourse analysis approach was used to examine “what is dominant discourse of baccalaureate nursing education” and “how the dominant discourse shaped nursing students' professional value and identity.”

Discourse has been defined as “a group of ideas or patterned way of thinking which can be identified in textual and verbal communications, and can also be located in wider social structures.”[17] Therefore, to better understand the dominant discourse and nature of contemporary nursing education environment, a multi-methods data collection, including individual interviews with baccalaureate nursing students, nursing educators and nursing board staff, nursing students' focus groups and direct observation of undergraduate theoretical and clinical course was used. The strengths of this methodological approach–using multi-method design–is that it allowed us to contextualize what participants said in relation to their everyday practice and to cross-check information and analyze their actual behavior and espoused views.

Participants were baccalaureate nursing students, nursing educators, and nursing board staff selected from five major educational centers in Iran, that is, Tehran, Isfahan, Babol, Sari (amol) and Yasooj University of Medical Sciences. For obtaining comprehensive data, we selected different nursing universities considering both geographical location and scientific level in Iran. Tehran University of Medical Sciences (located in capital of Iran) and Isfahan University of Medical Sciences (located on the main north–south and east–west routes crossing Iran) are high scientific level nursing universities in Iran. Babol and Sari (Amol) University of Medical Sciences (located on the north of Iran) and Yasooj University of Medical Sciences (located on the west of Iran) are middle scientific level nursing universities in Iran. In addition to the different nursing universities in aspects of scientific levels, availability convenience for researcher was also an important factor in site selection.

Data was collected by multiple methods, including individual interviews, focus groups, and direct observation.

Face-to-face semi-structured interviews were conducted in a private place that was convenient to the participants. The study population for individual interviews comprised 21 baccalaureate nursing students in different semester (3–4 students in each university), 20 nursing educators, and 5 nursing board staffs.

In addition, we used focus group method for data gathering. The method of focus group could be a useful method for achieving a comprehensive portrait of the topic under study. The advantage of focus group is, instead of the researcher asking each person to respond to a question in turn, people are encouraged to talk to one another, that is, ask questions, exchange anecdotes, and comment on each other's experiences and points of view.[18],[19] Ten focus groups were conducted at five universities (two in each university). Participants were 4–8 third or fourth year baccalaureate nursing students in each group. Focus groups were scheduled at a time convenient for the participants and refreshments were provided.

At the beginning of each interview and focus group, the participants were asked to describe one day of their theoretical class and clinical course, and then interviews continued with questions like:

What is your (educators) expectation or main concern about the nursing education?

How do you feel about being a nursing student?

What is the definition of nursing that formed in your mind during clinical training?

What comes to mind when you hear the phrase “nursing education?”

The questions were asked in an open-ended manner. All interviews and focus groups were taped and the scripts were immediately transcribed verbatim. Some interviews and focus groups were conducted in the researcher's university office in the university and others in hospital meeting rooms. Each interview lasted between 30 and 50 min, with an average of 40 min. In total, 71 students, 20 nursing educators, and 5 nursing board staffs participated in this study.

Observation was used for data collection based on the assumption that observation is a fundamental and critical method in discourse analysis. Observers watch what people do, listen to what people say, and record these activities. The focus of participant observation was on the students and educators' transactions and behaviors during theoretical course or clinical training. Twenty two nursing theoretical classes in various semesters (1–6) were observed. In addition, 5 groups (students and clinical educators in the clinical component of the general medical-surgical course) were observed for 2 days (total 10 hours) during the second week of clinical practice. Field notes and memos were written to describe the observations and later analyzed.

Data analysis

Data analysis involves viewing “language as a form of social practice” and attempting to unpack the ideological underpinnings of a particular discourse.[17] All data from interviews and observations were analyzed via the following steps: (1) choosing the text and identifying the explicit purpose of the text, (2) construction of major concepts, (3) processes of naming and categorizing, (4) construction of subject positions, (5) construction of reality and social relations and implications for the nursing.[16] In order to analyze data, several text analysis techniques such sd determining the themes, word selection, collocation, determining the key signifiers, contradictory poles, comparison, substitution, and intertextuality were used. During discourse analysis, the researcher continuously moves from surface to the depth of the text. Superficial analysis is concerned with vocabulary and linguistic properties of the text whereas deep analysis is concerned with hypertextual properties, that is, cultural and social structures of the text.

With regard to the validity and reliability of the data, member checking during data collection, peer debriefing, and an external auditor were used. An external audit was conducted by a nursing PhD candidate who was familiar with discourse analysis and checked all the steps taken in the analysis process. He reviewed the complete audit trail for this study and agreed with the findings. The researcher shared the results of findings with the participants to give them an opportunity to verify that her interpretations are in correspondence with their real-worlds. Maximum variation in sampling in terms of age, gender, level of academic semester, and years of experience as educator and universities with different geographical locations were considered in order to collect participants with a wide range of experiences and perspectives.

Ethical considerations

Ethical challenges in this study involved the assurance of confidentiality and autonomy for the participants. The present study was approved by the Ethics Committee of Isfahan University of Medical Sciences. Permission was sought from the participants for audiotaping interviews and the clinical educators, and vice dean for education in the school of nursing and midwifery had also agreed to participant observation.


  Results Top


The analysis focused on the dominant discourse of baccalaureate nursing education and the finding showed that nursing faculties discourse are characterized by science, theory, and research. Hence, the discourses explored are theoretical and scientific nursing, dominant biomedical discourse, caring as an empty signifier in academic discourse, and more than expected role of research in nursing education discourse.

Theoretical and scientific nursing

Findings showed that academics attempt to define itself based on “scientific knowledge” and theory, and nursing science was the basic signifier in the academic discourse. While clinical practice should be central to the mission and mandate of academic nursing, respondents believe that it is in danger of being displaced as its central focus. Our participants considered that the focus and concern of academic nursing education was on scientific knowledge, and theoretical education was more important than clinical education. In addition, findings demonstrated that educators in theoretical teaching were stronger that clinical teaching and they preferred to teach theoretical courses.

A nursing board member said that:

The importance of education in the development of nursing as a profession and as a science has been emphasized over the last decade. Therefore, the shift from hospital-based training to university education is the most important approach to improve professional status of nurses in Iran. We turned our attention to nursing science and nursing theories, and unfortunately by paying excessive attention to theories, we forgot that clinical training plays a fundamental role in nursing students' acquisition of professional capabilities.

An educator and dean of nursing faculty said:

Although according to my way of thinking, nursing is a practice-oriented discipline, but unfortunately we spend all our energy in planning for theoretical courses, and usually we select the best teacher for the theoretical course. Finally, we have to use novice educators for clinical education, who have little experience in clinical setting.

Findings from contextual observation demonstrated that educators preferred to work theoretically even in the hospital, and most of their clinical instruction was spent in lectures and theoretical discussions without direct involvement in patient care. In addition, most of the educators preferred teaching in theoretical class to teaching in the clinical setting, especially experienced educators. Indeed it is infra dig to them to go the clinical setting for teaching.

In most of clinical education course, our time was only spent on preparation conference or lecture papers for presenting. Our educators in theoretical knowledge are stronger than clinical practice.

Dominant biomedical discourse

The focus of education in nursing has changed over time with a decreased focus on biomedicine and an increased focus on nursing science.[20] However, the findings of our study indicated that biomedical paradigm was dominant and nursing concepts was marginalized in academic discourse. There was a tension between two ideological discourses, namely, biomedical discourse and caring discourse. Biomedical discourse was dominant and applying biomedical model in nursing education has distorted professional nursing territory and identity. Therefore, the image of nursing and nursing care is not clear and vague in students' mind.

One educator said that:

Our academic education does not prepare students to be competent in nursing care. Our theoretical courses are focused on biomedical-centered knowledge such as disease diagnose test, pathophysiology, medical cure, and are not focused on specialized nursing care.

A nursing board member said that:

Unfortunately, our educators and students think the best nurses are the nurses who have more medical information. They are proud of their high medical information such as details of surgical procedures because they think biomedical concept is specific science but nursing concept is general.

Observation confirmed interviews and indicated that, in theoretical classes, educators gave student an extensive range of biomedical topics such as disease-related pathophysiological information; however, they do not spend even 10 minutes on the nursing care and nursing processes in a 2-hour class. The PowerPoint presentation displayed a list of concepts as medical information and educators taught nursing care in a very general and nonoperational form and when students were tired and sleepy at the end of the class.

Caring as an empty signifier in academic discourse

The principle of specialization refers to the way academics and their discourses are constructed as specialized and distinctive. It captures the relative emphasis on who you are and what you know. Disciplinary specialization may center on the character of those who may legitimately claim particular knowledge or, instead, the emphasis may be on discipline-specific cognitive skills: what knowledge is claimed and how it is obtained.[21] Observation of theoretical and clinical courses and interviews showed that nursing specialized concepts such as caring not established clearly, definitely or operational. Caring was as an empty signifier (as a signifier with a vague, highly variable, unspecifiable or nonexistent) in academic discourse. There was a weak specialization and less caring attitude among nursing students and educators. Some clinical educators reported a lack of clarity in relation to what was expected from caring in clinical practice and how this was formalized. Most of participants said that we know caring is a really important role of nursing but it is hard to say what it comprises.

An educator believed that:

It is unclear how the caring dimension is actually taught. This is because educators lack consensus on what caring actually is and how it can be taught.

One senior student in focus group stated that:

We often feel confused and depressed; actually, we do not know what is expected of us as a professional nurse with special caring role in the clinical setting. We are responsible for just about everything. We should be performing our nursing duties, not being treated as guards, physicians' assistance, cleaners, or nurses' aides. I don't know, who are we really?

A student described her experience as:

I think implementation of nursing process is one of the most important role of nursing care. Always our educators put great emphasis on nursing process. But it is declarative and not operational, more like an encouragement. We talk for hours about caring and nursing process in hospital and we can't perform nursing process steps in real worlds. Actually, educators really don't have a clue how to perform nursing process for patient.

An educator said that:

Nursing education should focus less on vague theory and more on bedside caring and a holistic view of the patient.

Observation of clinical course in hospital confirmed interviews and indicated that, in clinical course, students spend most of their time in doing technical and mechanical care such as giving drugs and injections and dressing wounds without individual and holistic care. In addition, educators preferred to explain nursing care theoretically, and their clinical instruction about caring or nursing process presented by theoretical discussions without direct involvement in patient care.

More than expected role of research in nursing education discourse

An important concern for most of the academic members was research and publishing articles, and they spent a lot of time in researching in academic environment. Some of participants believed that nursing research has a tremendous influence on current and future professional nursing practice, thus, rendering it an essential component of the educational process. According to observations, not only postgraduate student were encouraged to researching but also undergraduates students were encouraged to writing research proposals, researching, and presence at the congress. However, academic members believed that research and article quality is more important than their quantity, and academic education should improve the quality of research for solving nursing problem.

One of the academic members expressed:

It's so good that nursing academic environments give so much importance to research, but it will be better if we investigate on the nursing concept that lead towards promotion of nursing professionalism. We should use research to answer questions about our practice, solve problems, improve the quality of patient care, generate new research questions, and shape health policy. Unfortunately, not all research and published articles are scientifically sound and usually our research is a repetitive task done for some advantages such as job promotion.


  Discussion Top


The results of our study indicated that academics attempt to define itself based on “scientific knowledge” and the nursing faculties seek to socialize students toward professionalism to raise the occupation's status by emphasizing the scientific/theoretical basis of nursing and research. The dominance of biomedical discourse in the theoretical basis of nursing education, instead of socialize student with strong identity, has trained students with role ambiguity, and the main aspects of nursing such as caring have become vague and marginalized in the educational sphere. This supports McNmara's (2010) discursive study, who showed that the state of academic nursing in Ireland is that of a field characterized by low autonomy, high density, weak specialization, and disciplinary immaturity.[22]

By a shift from hospital-based training to university education in Iran, today the nursing faculties prefer to devote more consideration to theoretical knowledge for increasing their professional identity, and a marginalization of clinical concepts is clear in the present discourse of nursing education. Other studies in Iran showed that, although nursing education shifted to scientific nursing and high theoretical knowledge, nursing educational content for undergraduate nursing is perceived as medical-centered, noncontextual and non-nursing, and hence this situation has led to weakness in clinical knowledge in nursing education.[11],[23] Chua and Clegg in their study indicated that nursing educators actively used a “scientific knowledge” rhetoric as a means of separating nursing education from actual bedside care.[24] Nursing is a practice-oriented discipline, with the practical aspects forming the main sphere of the profession so that the nursing faculties can devote more consideration to clinical education.[25] Domination of biomedical discourse in nursing academic atmosphere was clear, and this is supported by the findings of yazdannik et al. (2012) in Iran; they indicated that the dominance of medical discourse in health system has made it to impose its values on the educational system through biomedical paradigm. Therefore, instead of training nurses with a strong identity, it has trained self-alienated nurses, who not only do not feel professional decency but have also forgotten being a nurse and have caught professional Alzheimer's. Furthermore, Roberts believes that nursing values in the field of caring are seldom recognized because medical values and models have been recognized as suitable and institutionalized. The nursing identity has been overshadowed by medicine, which has made all areas of health its own territory.[26]

Our study showed that the core concepts of nursing such as caring and nursing process not institutionalized clearly. Given the lack of consensus among faculties about the meaning, relevance, and teaching of caring, the question remains: How students learn to be caring if educators do not necessarily teach it?this is not surprising, as the literature in nursing continues to refer to caring as a nebulous, elusive, and problematic concept in nursing education.[27],[28] A conflict between the genuine nursing care, the students' wanted to give and the professional caring reality they were facing [29] and a conflict between theory and practice and having no plan during clinical courses is a common problem for nursing students, often leading to confusion in caring and role ambiguity.[30],[31] In relation to the improper implementation of nursing process, analysis of a systematic review showed different challenges in performing the nursing process. Intangible understanding of the meaning of nursing process, difference in attitudes toward the nursing process, lack of awareness of the nurses, and supportive management of problems related to recording the nursing process were the main challenges in reviewed literatures.[32] Apesoa-Varano believes that while nursing student's think of the occupation as a profession, their understanding of what makes a “good” nurse is deemphasized in the model of professionalism espoused by their educational program. Consequently, prospective nurses must reconcile their expectations of nursing as a caring occupation with the professional ideology of the program.[27]

Research was another important part of nursing discourse in academic atmosphere; however, it seems that research quality sacrifice for its quantity. Other study in Iran critique quality of academic members nursing research and they indicated that research should direct to solve nursing problems and improve the quality of nursing care.[23]


  Conclusion Top


This study, as the first of its kind in the Iranian context, explored dominant discourse of academic nursing education. Our study showed that nursing faculties seek to socialize students by emphasizing the scientific/theoretical basis of nursing and research with the dominance of biomedical discourse. However, scientific and theoretical development is a sign of undeniable progresses of nursing education in Iran but professional values which are basis of professional identity have not been institutionalized in academic discourse. It fails to conceptually grasp the reality of nursing practice and the result is an impoverished theoretical discourse. Hence, the analysis highlights the need for academic nursing to focus on building specialist capacity in specific areas of theory, practice, and research to make a distinctive discourse for academic nursing, reconfigure its relationships with clinical nursing, and formation of a strong and new discourse, which contains articulation of signifiers extracted from the nature of the profession.

Acknowledgement

This article was derived from a Ph.D. dissertation of Sepideh Mohammadi with project number 393584, Isfahan University of Medical Sciences, Isfahan, Iran.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors have no conflicts of interest.

 
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