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NURSING STUDENTSI EXPERIENCES OF AUTONOMY:

A CRITICAL FEMINIST APPROACH

BY

KATHLEEN M. BROPHY B.N., R.N .

A thesis submitted to the School of Graduate Studies in partial fulfillment of the requirements for

the degree of Master of Education

Faculty of Education MemorialUniversity of Newfoundland

September, 2000

St.John's Newfoundland

ABSTRACT

The purpose of this study was to explorefemale nursing studen ts ' experiences of autonomy during their nursingeducation programs.The methodo logy wa s a crit ical femi n i s t ap p r o a c h using qualitative me thods.

The participantswe re ten female nur se swhoha d graduat ed from an undergraduate nursing program within the past two years. Results indicated thatal t h ou g h the participants coulddescribe expe r iences th a t bothenhanced the ir autonomyand deprived them of autonomy, theydescribedan overall lack of autonomy during their nursing education and they appeared to be an oppress ed group.Autonomy , they found, was difficult to attainwhe n the learning environment was controlling , inflexible, intimida ting , and posed unrealisticexpectations.Factors that en h a n c e d their ability to be autonomous includedcollegial relationships, trust and independence, clinical compet ence , and construc tive fe e d b a c k.. They revealed th a t a result of oppression was powerlessness, passiveness and an acceptance of oppression.

ACKNOWLEDGMENTS

I wo u l d like to extend my appreciation to a number of people who were instrumental in assisting me complete thisthesis.

First, and foremost I would like to thank the te n nurses who were the participants in this study, all of whom tooktime from their busy schedules to participat e in this study, and without whom this study would not have takenplace.

A special gratitude is extended to my thesis su pe r v i s o r, Dr. RosonnaTi t e , for her expertise, support, and accessibilityduring thecompletionofth i s thesis .

I wo u ld like to ackno wledge the faculty of the graduateprogramin education for ma king this programa most enjoyable and challenging experiencefor me.

Thank-youtomyemployerthe Health Care corporation of St. John'5 for the scholarshipsand tuition reimbur sement tha t I received during the completionof the graduate program.

To my colleagues at the Centre for Nursi ng Studies for your advice and supportove r the pastfou r years, a sincere thank-you.

III

Last , but not least thank you to my husband Raymond and childre n Juli e, Nancy, Pe t e r, and Stephen for your patience and und ersta nd ingduring thema ny time s .. I had to work on my thes Ls" es pe cially during thi s past few months.

IV

Tableof Contents

Abstract ••. .•• . ...••..•..•... .•.•. . .• . ... . .••ii Acknowledgments... . ..•... ... ... . .. . . ..• iii Chapte r 1 Backgroundof the study ..•...• •. .• • . . . 1

Introductio n 1

Purposeof the study 3

Significanceof the st udy ... ... ... . ...• .3

Definitionof terms ... ... . 6

Chapter 2 Review of Rel atedLiterature .• •....• •.. ... .• •7 Iss u e s inNursing Education .... .•.. ..• . . . .7

SexualStereotypes . 7

Sexismin nurs ingeducation 11

Power Relations 12

Behavio r ism..• .. . •..• •..• • .. .• • •.. . .• ••12 Humanism..•. .••. .••. .• . ....•. . ...15 Feminism ..• •. . • .. . •... • ...• •... • . . . . .17

Criti calSocial Theory 21

Autonomy- Nurs ingLiterature 24

Personal ityconsiderations 25

Edu cat iona l le v el ... ... . ... ..•.. . . . .29 Nursing role considerations... .. ...• ...31 Adult educat ion- Relevanceof Autonomy 32 Andragogy and Humanism... .. ... . 33 Theories based on ch a n g e s in cons ci ousnes s 38 Relatededucationa l li t e r a tur e...• . ....• •. • . . 41

Summary .

Resea rchqu est i ons

... . . . 43 .... . 44

Chapter3 Methodology . Rationaleforme th odo l og y

. 46

.... . . ...46

The parti c ipants 49

Data co lle c tion.. Researcher's role

.50 .. ..• ... ... .... .. . .. .53

Ethi cal issu e s 54

DataAnaly sis 56

Tru s t wor thine s s . 57

Limi ta t i ons 57

Chapter 4 ThematicAnalysisand Interpretati on 59

Aut o nomy : Th e is su e 61

An unfa mi li a r con c e pt 61

Perceive dor real aut on omy 63

Pivotal rel a t i o n ships: The import ance 66

Stud en t - in struct o r . 67

St ude nt - staff nurse . 72

Studen t - student .. . . 80

The learn i ngenv ironme n t: Its imp a c t 83

Inst ructo r-d ire c t e d 84

Inflexibl e practices . 88

Un rea l ist i cexpectat i ons 92

Inti mi d a t ion 96

Au to no mous experi e n ces:Con tri b ut i n g Fac t o r s 101

Collegia l re lationshi p s 101

Tru s t andind e p e nd e nc e 105

Cli n ica l competence 108

Con s tr ucti v e fee d b ack. .. .... .. . . 110

Oppressiveexperien c es:The ou tcome 115

Powerlessness 11 5

Le ar n ed Pass i ve ness .. ... . . 119

Acc eptanc eofOp pre s s ion 123

VI

Chapter5 Summary and Discussion ..•. ..•• .. . .•.. . .• •••12 9 Introducti on .••.. •..• •..••..• ... •••..•• .. .. . • . .12 9

Aut o n omy 130

Oppression .•. .• •. .•. ..•. . ..•• . ..• . • . • 135 His t o r i c al Perspec ti ves..• • .. ••• . • . •. .••••13 9 Nu r s i n g education- The Feminist Perspec tive...143 Implicat i ons for Adult ed u ca ti on ...••.. .• ••.. ...147 Implicati ons fo r Nursing Education.. ... . .• ••. .. ..149 Impl i cationsfor NursingPr a c ti c e .

Impli cat ionsfor FurtherResearch .

.1 52

. 15 4

Conc lusion .•...••. .•..••..• •. . • • . . • . •...•••.. . . 155

References

AppendixA: Inte r v i e wGuid e

.1 56

..178

AppendixB: A.R.N.Nre q u e s t 179

AppendixC: Le tte r ofCo n s e nt 180

VII

CHAPTER ONE Backgroundof the Study

Introduction

The history of nursingeducationin Newfoundlandwill record 1996as ala n dma rkyear beca useof the tr a n si ti o nof all nursing edu cat i onprograms tothe universitysetting. Thisoccurred sixty-fourye a r s afte r the WeirReport (19 32) recorrunended that nur si n g education shou ldmove fromhospital based settings to the gen eral ed uc a t ion system, preferably universit ies (Ker r, 1991 ).Although a university school of nursing was establishedat Memoria lUniversi tyin 1965, the diplomaschoo ls ofnu rs i ng con ti nued to pers i s t, and were abl e tores is t the movetothecoll e g e system , despite this trend in the restof Ca na d a .

A new collaborativenursi n geducation curr icu l um was impl e me nt e din all sc h oo l s of nur si ng in Newf o und l and in Septemberof 1996, andthis was the startof what is hoped to be a major ch a n g e process in nursi ngedu ca tionin this province. Howeverwhetherthis becomesa superfi cia l or subs ta n t i ve ch a n g e dependsonma n y fact ors. Blenkin, Edwards and Kelly (19 92) described "superfic ial"cha n g e asli t t l e more thannew waysof ca t e go r i z i n gor pa ckag ing fami l iar

products, and substantive changeas affec ti n gthedeepe r structures of the curriculum implyinga fundamental reordering of categoricalme a n i n g s (p.3l).

Nursing theorists for the past fifteen years ha ve been call ing for a substantivechange inthe del iveryof nursing educat ion - a tr a n s f o rma t i o n seen as away of permitting nursi ng tore a l ize it s goal ofpr o fe s sio n a liz a t i o n and autonomy(Benner, 1984 ;Pitts, 19 85; Bevis, 19 8 9a ; Watson, 1989; Bau gh n, 1995; Wade, 1999). Nurseeducatorsan dnu r s ing students must take advantage of this "p eri od of change"to pu t voiceto th ei r viewsand to helpeffec t a substantive change.This can be achieved through the exp lo rationof issues that affect the deeperstructuresof nursing education.

The elusiveness of autonomyfor nurs e s is oneof those issues that needed to be addressed.Autonomy is after al l an essentialelemen t of professional status (Schutzenhofer&

Musser, 1994). In a time of major health care reform nurses have an opportunity to be key playe rs.Nurseshowever mu s t be prepared to shape change , and this type of proac t ive nursing r equt r es autonomous practitioners.

Purposeof the stud y

The nu r s ing ed uc a t i o n process plays a major role in the developme n t of autonomyinnursing students andthus the fu t ure nurs es . Explo ratio nofwh a t is happening in today's nursingeducationpr o c e s s is needed to uncove r someof the answers that have continuedto evade nurses.Therefo reth e purposeof thisstudy is to explore,describe and und e rstand the exp eri encesof nurs ingstudents in relationto issuesof autonomy.

Sig nificanceof the Study

Be n n er (1984), a lead ing nu r sin g theor ist,dre w attention to nurses' lack of pr o f e s s i o n a l autonomy aswe l l as society's general lack of acknowle dg mentfor the value of theirwo r k.Rob erts (1983) described nurses as an oppressed groupwho are controlled and exploitedby physicians and admi ni s trators who havegreaterprestige, power, and status. In sup po rtof thisth e o r y of oppression, Ro b e r t s found that nurses exhibitpersonality traits of otheroppres s ed gr o ups suchas low self-esteem, inclination towards self-hatred , an d frequent dislike of me mbe rsof their ownprofe s si o n and gender.

Watson (1989) described the relationshipbetween

wome n ' s op p res siongenerally and nurses' oppression specifically , in both the edu c at i o n andthe med i c a l systems.

The tendency for op pressed gr o up s to oppressothe rs is depict ed by nursing 'scontinuin g hi s t o ry of oppressi ng its young and thereby socializing a ne w generation into asystem of controland oppression (Watson , 1989).

Montgome ry (1994) wr o t e that although most nurses have becomeaware th a t they wo rk in hierarchical and pa tr iarchal organi z atio ns , fewnurses recognisethatthe same male model dominate s ma n ynursi n g educa tio nprog rams , even those des i g ne d, deliver e d ,andcontrolledby nurses. Bo u g h n and Wang (199 4) st at ed "in the traditiona l educational pr o c e s s nurses ar e socializ ed to internalize a subculture that in c l u de s norms and values ass i g ne d to perpetuatethe privileged power status of thedomi n an t group, the med i c a l establishment" , (p. 113). Many schools andinstructors un wi t t i ng ly upholdthe masculine view asthe correct view (Shellenbarger , 1993). Domination is most complete wh e n it is not eve nrecognize d , sugg estsFreire (1986).

The viewsexp res sedby these nursing wr i t e r s are reflectiveofthe views of Appl e (1990).Apple holds that

"e d u c a t i o n a l institutions act as agentsof cultu raland ideolog ical hegemony , and are thema i n agenciesof

distributingan effective dominant cultu r e" , (p, 6). This then le adsonetopo sema ny question s abou t what is happeningin nursingeducat ionin Ne wfoundl a nd. Is nurs ing ed u ca t i on inNe wfoundland perpe t u a t i n g the domina t i on by the el i tes, and the sub s eque n t oppr essionof nur s es ? Are nurs i ng stude n t scont inuin gtobe so c ia l iz e d into a pro fessi on whe r eautonomy isnot beingrealizedas a student? If autonomy is not bei n g reali zedasa student wha t implicat ionsdoes this hav e for futur e nur s e s ?Ifautono my is be i n g real i ze d as a student , how mightthose studen t exp e r ien c es be usedto enh anceautono myin othe r stud e nt s ?

The wri t i ng s ofMo n tg omer y (1994) , Boughnand Wang (1994), an d Shellenbar g er (1993) aler t ed me tothe possibilitytha t nurse educators , although they value au t o n omy, may not be awareof how the yma y be con tri b uting to or hindering th e actua l achie ve mentof autonomy in their st uden ts. Therefore I fe l t that a stu dy of"th e exper i ences of the stude nts told by the students" would be especially timely in exploringproblems wh i c h seem to continue to persist for nurses, andwhich may beoriginating in the nursin geducatio nprocess.This study can therefo re as s i s t nurseeducators andnursing studentsto confront wh a t is hap peni ng in nursingeducation, andwi ll add to the bo dy of

knowledge wh i ch seeks to describeand understand how nurses' education exper Lence s and autonomyare re l a t e d.

Definitionof terms

Fo r the purp o s e of this study thefollowing termsand definitionsapply.

Autonomy; The fr ee d om to make independent decisions;

personal freedom, and freedom of choice concerning student lea rningexpe rLence s ,

NU:J:' s ing:In st:J:'uctQ:J:':The official re pre s e n t a tiv e ofth e school of nursing; the personresponsible for facilitating student learning.

St a f f Nurse: Th e nursewh o is re s p on s i b l e for client care inclinical set tings.The nu r s i n g student would at times be assignedtowo rkwi t hth i s nurseand the nurse's assigned clients.

CHAPTER TWO Review of RelatedLiteratu re

Introduction

This chapterincludes: (a) an overviewof curre ntissues and trends in the nursing education literature; (b) an in- dept hanalysisof there sea r c h on autonomyin nursin gand nursing education ; and (c I an analysis of the adul t ed u c a t i o n literatureand adult learning theoriesinre l a t i o n to autono my.

Issues in Nursing Ed u c a t i on

The nur si n g literatureand researchof the19 8 0 s and 199 0 sis abun d antwith criticisms of th e he a lt h care system andtr a d i t i on a l nursing educationprocesses. Recurring themes intheliteratu re relate to sex ualstereotyping, patriarchalpractices, power relations between doctors and nurses,authoritarianpracticesin nursingeducation, and flaws in the teacher-student relationships.

Sexual Stereot ypes

A number of writers have described how female dominance of the nursi ng professionhas led to sexual stereotypingof

nu r s e s and thedoubl e socializationof fe male nurses in t o sub s e r v i ence, firstas fe ma l es andth e nasnur s e s (George&

Lars en, 1988; Wat s on, 1990 ;Baughn s Wan g, 19 9 4 ). Cummings (1995) descr ibed how gender dif fe r en cesrel a te d topowe r are very import a ntin today'shealthcareorg a n izations. Most traditional he a l th care organizations hav e been organiz ed like the traditio nal fa mi l y withmen (administra torsand physicia ns) at thehead socialized to issue ordersand give direction, whe r e a swome n (nurses) have beensocialize d to sugge st and qu e s t i o n rathe r th a n state ideas (Cummings, 1995). Despite the feminist movement and increasedequality for women in society , research still suggeststhatpresent da y hospitalscontinue to be patriarchal wit h a dispar ity be t wee ndo c t o r s and nurses that is based on in e qua lities between men and women (Allan, 1992; Sweet &Norm an, 1995).

Howeve r , not onlyhas thesex role st e reot yp i n g of nurses been implicated in crea ting apassive , powe rless and depende nt publicimage of thenurse , it has also created the media ima geof the nurse as a sexobject (Kaler, Levy&

Schall , 1989;Cummings , 1995). Ta y l o r (1993) suggestedthat the ima ge of thewhi t e, young,middle -classfe malenurse pe r s i s t s, and that th e me d i a image s of nurses as angelsor whores often remain unchallenged by the profess io n.

Muff (1984) stated that the major nursing stereotype, the unintelligent female, creates public expectations that affects who will be drawn into the profession and who will shy away. Pillitteri (1994) did a comparative study of nursing and nonnursing college majors, using a seven-point likert scale questionnaire to measure attitudes towards various career choices. The findings showed thatthe nonnursing majorshad negative images of nursing, viewing it as a femalecareer that was less challenging, had less responsibility and less pay than other careers (Pillitteri, 1994).

Kalish, Kalish, and Clinton (1982) related how negative stereotyping not only influences the public view of nurses but also has an impact on the nurse's self image, thereby possibly limiting the roles of the nurse. Newton (1981) found that the public would not accept an autonomous professional role of the nurse because it was in opposition to a persistent public ideal of the nurse that focuses more on nur tu rence , service and subservience.

Not only are female nurses affected by negative female stereotyping, but as Tumminia (1981) and Perkins, Bennett, and Dorman (1993) noted, men in nursing struggle wi t h issues of gender role conflict and minority status. Beliefs that

10 malenursing students are homosexual are per va s i v ein society making it difficultfo r the student to integratehis new role (Tu mmi n i a, 1981;Anderson, 1993).Will ia ms (1993) noted that men who"c ro s s over"genderro l e s upset gender assumptions, and are oftensuspectedofno t beingmasculine. Perki nset a!. (1 9 9 3) foundth a t men in nursing try to diminish the like l i h o o d of being recognized as a nurseby pursuingspecial i t ies suchas anesthesia and psychiatr ic nu r s i n g . Williams (1995) described how male nurses are viewedby thepublicas being underachievers , and this may be the reason why men stay away fromth e profession.

Interestingl y, althoughnursing is a female-dominated professionmany authors have also reportedhiddenadvantages forme n in nursing.Gans (198?) described how men are paid on averagemoreth a nwo me n in nursing, are concentra tedin more prestigious positions, and are over-repres ent edin management posit ions. Wil l iams (19 9 5) describeda study invol vi n gind e p t hin t e r v i ew s of 32 male nurses over a five- year period.The findings of this study indi catedthat me n receive preference in hiring, arefa v o r e dfor hi r i ng in areas such as emergency departments, are treated with more respect by physiciansand are favoredfor promotion.

Williams (1995) reportedthat ironically the fi ndingsalso

11 ind i c a t e that the advantages only extendto those men who exhibit conventional male characteristics, including a heterosexual orientation.

Sexism in nursing education

Shellanbarger (1993) reported how sexism exists in many nursing classrooms without the teacher or student being aware of it. In support of this view, Shellanbarger wrote of how faculty members frequently know the names of male students, but not of female students, contributing to the invisibility of female students and the lowering of the female'5 self-esteem. Shellanbarger described how only one of seven nursing fundamental textbooks included Gilligan'5 work on female developmental theory, yet all seven included the developmental theories of the male theorists Erikson, Piaget, Freud, and Kohlberg. Cummings (l995) cites a study by Brookfield (1982) in which male students admit to receiving preferential treatment in nursing school.

Shellanbarger'sviews are consistentwith research by Sadker and Sadker (1 98 8 ) who found that male students in elementary schoolsre c e i v e more teacher attention, receive more praise and are addressed more frequently by name. Further research by Sadker and Sadker (1990) (as cited by Masland, 1995)

12 in dicat e d tha t theprefere n t i a l tr ea t men t ofma les continu e d in colleg e. Maslan d (1 995) stated"Teache r s restri ctgirls' po t ent ial to achi e v eand ga i n self-estee m wi t ha va rie t y of behavior s tha t signala greate r beli e f , andpreference fo r, thei rmal e students - despitedecades of researchthat ha s calledatt entionto thesepractices" (p.19).

Power Re l a t i on s

Many nursingtheorists hav eaddressedthe hierarchical and pa t r i a r ch a l ma n a ge me nt structure of the healt hcare system and its subse quen t adopt ionby the tradi t ional nursingeduc at i onpr o cess (Benner , 1984 ; Be v i s, 198 9b;

Watson, 1990;Tanner, 19 90 ).The aut ho r i ta ria n pra c t i c e s in nursing ed u c atio n, resulting fromthis hi e r a r c h i c a l structur e combine dwith abeh aviorist iccurric ulum mo d el, have been conde mned by va ri o u s theor ists espou sin g changes in the powe r structures with in nursingeducation ba sed on theoriesof humanism, feminism, and criticalsocial theory.

Behavior ism

Be v i s (19 8 9b ) described howa major turn in nursing curriculumcame wit h the introductionofth e Tyler Be h a v i o r i s t modelinthe 19505, whi c h nursing ac cred i t a t i o n

13 bo d i e s and schools of nu r s i n g bothreligiously embr a c ed.

Durin g th e 19805 nursingtheorists , inc l ud i n gBe v i s, started to question the oppressive nature of the behavio ri s t curricul um mo de l. Bevis (1989b) descr ibedbehavioral object ivesas re presen t ingminim a lachiev e ment le ve l s, being usefu l for skill traini ngand inst ructio nand leaving no room forthe student '5 indivi dualinter est purs u i t s.

Bevisclaimed that behaviorismis unable to ad d ressthe values and qualitie s whic hshe desc r ibesas being characteristicof an educatedperson : criticalthinking ; emanci pat ion fr om oppressiveor confo r mistthinking ; cri t icalsocial consciousne ss ; vision of th e assumptions und e rly ingissues and the assumptions under lying as s ump t i on s; insi ght ; fo r es ig h t; antici patoryinventiveness ; int u i tio n ; andthe abilit y to engage in dialogu e rat h er than po l emi c s.

George and Larsen (1988)pre senteda similar viewas Be v i s stating :

Curre n t nursing educ ation pr o ce s se s serve to stifle initiative , creativity andac a dem icpotential;little support is givento nurseswh o arehigh l y

in di v i d u a l i s t i c; wh o takeaction inde pe nde n tly, and who exp ectfinancialand other rewards.The pr o c e s s of

14 nursing education requires careful examinationto reducethe structurein nursing cur r i c u l um andto in creas e op po rtu nity fo r inde p e nd ent lea r n i ng and to re wardrisk-takingbe ha v i ors . Nursing studentsneed to lear n to lea rnandto exp eri enceacademic progra mming wh i c his intellectuallystimulatin g (p .72).

A qualitative study byDi eke lma n n (1993), using Heidegge r ianphenome nology toanal yz eth e lived exper i en ce s of students andte a ch ers inba c c a la urea te education , supported the inadequ aci es , wh i c h Bevis identified in the behavioristapproach.Theviews of Bevis arealso support ed by thewr i t ings of Benne r (1984) , Watson (1 9 90), and Tanne r,

(1990) .

Mun h a ll (1981) de s c ri b e d how nu r s i n g philosop hyhad becomehumanistic-e x istent i alist , holistic , s ubjectLv e, intuit ive, ph en ome no l og i cal, andhuma n - e xpe ri e nc eorient e d, bu t note d that nursingeducatio nin pract ice had not experi e nc ed this shift in parad i gm.Ac c ord ing toMun h a ll this dissonancehas cause dschools to write ph i l o s oph i e s tha t were humanisticand caring -oriented ,while planning curriculumthatwe r e objectives-based and oppressive .

15 Humanism

Anumber of theorists have promoted a move from the traditional behavioristcurriculum model to a model based on caring as the moral context of nursing with a resulting change towards a moreegalitarian nurse-teacher relationship

(Watson, 1990; Tanner, 1990; Bevis, 1989b; Noddings, 1984). The failure of a patriarchical health care system and a call for its transformation is addressed by Watson (1990) and Tanner (1990). Watson described how the present health care system operates within a larger structure that now has to be openly acknowledged as patriarchal. where caring is viewed as women' 5 work which is neither valued nor considered as important as the work of men.Watson called for a revolution in health care, and with this a revolution in nursing education.Watson'sview was that nursing curriculum should be transformed by introducing a new caring modality at all levels of nursing education including faculty-student-administration relationships.Watson felt that such an approach would prepare professionals who are morally accountable and autonomous partners with society. Tanner (1990) discussed how the health care system, dominated by a patriarchical ideology of control is in crisis. She called for a revolution in nursing education to

16 prepare nurses to transform the health care system. In order for this to happen , Ta nn e rfeltthatnursi ng education mus t undergo a transformationinwh i c h carin g is a core value . She described how the interactions between students and teachers is vital indef i ni n g for the studentthat there is value inwha t theythink , andthat they aresafe in exp ressi ng it.

Be vi s (1993) des c r i bed how ho s p i ta lsandphysicians controlled nursingpr a ct i c e and educationuntil recent t imes , and s t i l lexer c i se control and barriersto nursing education and practice. Shedr e w an analogy to what she descri bedasnu r si ng teache rscont rol li ng thei r students . She prop os e da newmodelfor educationbased on student empowermentand car ing , whe rethe teach e r developsskill in educating learners rather than trainingthem . Be v i s (1993) sta t e s "Cari n g doesnot just instruct; it ed uca tes" (p .104).

Noddi n gs ' (1984) mod el for moraledu cat i on stres se s that caring is a relationship characteriz ed by three processe s na me l y dialogue, practice,and conf irmation. In this mode l tru s t is enh anced be c a u s e the student is consideredmore importantthan the subjectma t t e r.The teacherdoes not me r e ly impartknowl edge but rathe r engages in a cooperative effortwith thestu de nt thr oug h sharingand reflection. In

Noddings ' view caring is learned and it follows that caring mustbe ta u g h t withtheteacher being a model for the student.

Leininger (1988) described caringas the"co r e" and the

"essence" of nursing. She further statedthatnursing students need to be taught from the first day in their programs about the concept of car e and howit is used to deliver patientcare. Aqu ali t a t ive study by Nelms , Jones , and Gray (1 99 3), exploringcaringfromthe perspective of the student , highlightedthe impo r t a n c e of role-modelingby the teacher as a way for students tole arn caring.

Pitts (1 98 5 )de s cr i b e d how a covertcurriculumin nursing educationdeprived the student of personal powe r by emphasizingthe valuesof social serviceand wor k , the r eby se ndi ng the mess ag e thatpers o na l gratification shouldnot be expect ed. Pit ts called for a change in the dominant model of nursing education to allowfo r more egali ta ri an relationships .

Feminism

The nursingliterature indicat esthatnu r ses are now beginning to recogni z ethe eff e c t s of sexismon nursing and wome n, and to consider nu r s i ng, women's health , nursing

18 edu ca t ionand nursingresea rchfroma femi n i s t pe rs p e cti v e (Chinn &Wheeler, 198 5; Sher wi n, 1989; Hed in &Do no v a n , 19 8 9; Heze k i a h, 1993; King, 1994; and Sigsworth , 1995).

Chinn andWheeler(1985) claimedthat themaj o r contribu tionoffe mi n i s t thi n k i n g in relat ion to nur sing is the basic tenetof femi ni sm - thatwome nareanop p r ess ed group. They felt that becausenursing has traditionally been a femaleoccupation , "it is essential to understa nd the oppressionof women to gainin s ight in t o some of the most persi s t e nt problemsin nursing" (p.76).

Vance, Talbot , McBride and Mason (1985) described how feministwomen and nurses have historicallyhad an une asy alliance,withmu ch of the energyin thewome n' s move me nt being di r e c t ed towards opening up non -traditionalfields of stu dy and wo r kfor wome n. The y descr ibe d how fe mini sts hav e sometimesfailedto lookbeyondthe inaccurate sex i st stereotypesof nurses , ignoring nursingas a caree rchoice or as an authentic vo i c e for wome n' s rights. Inst e ad nursi ng has been seen"as oneof the ultimate fe male gh e t t o s from wh i ch women should be encouraged toes c a p e" (Vance e t al.

1985, p.282). Al t h o ug h nursinghasnot alwaysemb r a c e d feministideology , Vanceet al., fe ltthat moreand more nurses ar enow identifyi ngwith fe mi n i s t goals and

19 ad voc a t ingi tas model fo r nu r si ng education .

Dais ki (1996) repor t e d a qualitativestudy of ten sta ff nurses' perspectivesof hospital power structures. Results of the study ind i c ated that at least halfof the nurses in the st ud y recognize dfeminism as having ef f e c t e d positive change s for women .Howev er th e y express eddoub ts ab o u t fe minismbeing acceptableto most nurses as amea nsof emancipation , and not one of themhadev e r discuss ed this topicwi t hothe r nurses. Dais ki stat e d"i t seemed to be a taboo subject" {p.30).

Ba u g h n and Wan g (1994)describe d how in the traditional patriarchalcultur e women are socialize d to be subservient and in the traditionalnursing educa tiona l process students are socializedto thi s subserv ience. Howeverthey reported positive changes in students' attitudesandbeliefs followin g comple tionofa femin is t -oriented women' s hea l t h course. Pr e- t e s t / p o st-te s t re s u l t s demonstratedchanges in thear ea s of profes sionalactivism, re gard for self , nurses, andwomen , andsocial act i v i smagai n s t se xis m and vi o le n ce.

Simila rly , Beck (1 9 95 ) describeda study ofamodelfo r classroominstructio nin nursi ng , based on cooperative learningand feminist pedagogy.The re su l t s indicated that feministpedagogy chan ge d th e cla ssroominto amor e

20 egali tarianstructure, allowing students andtea c h ersto shareinf orm a t i onand points of view inanop ensetting .

Th e characteristics of a feminist educ a t ion, ide ntified byfemi nist wr ite r s, and referredto as a "freeing educa t.Lon" (Hedin&Donovan , 1989) includeempowerment, re la t e dn ess , connect e dne ss , whole ne s s, inclusiveness , values-dr i ve nand interactional. According to Sher win (1989) tea c h i n g influenc e dby feminis t ph il o s op h y an d me t h od o l og y doe s not involve a processwherethe teacher is the wiseone and thestudent the naiveone. Rather, it is a proce s s where equalrel ationshipsare encouraged (Sherwin, 1989).

Hezekiah (1993), wh il e advocatinga feminist fr a me wo rk for nursing educat ion , identified the followingfive basic feminist process goals for the classroom, "Atm o sp h e r e of mutual respect, tr ustand conununity , shared le a d e r s hip, coop e r at i ve structure , integ rationof cognitiveand affective lea rning ,and action-oriente dfield work" Ip , 56). Hez ek i a hfeltthat edu ca t i ngwomen to the realityof the structuresth a t oppress themin a climate of mutual re s p e c t, collaboration , and tr u stwo u ld help themtake constructi ve action to changethe ir lives.

Wh e e l erand Chin n (1991) stronglyadvocatedfor student empowerment, wh i l e describingthe power imbala ncethatthey

21 hadfoundin mostnu r sing classrooms:

The valuesthat we have fo un dtobe consistent l y we l c omed by classroom pa r t i c ipa nt s are empowermen t for all and demystificatlon of content and process (especially proc e s s e s for grades). Eve n thoug hthese valuescou l d be ass umedto be central towha t ed uc ation is all about,theyare ironica lly consistently underminedin most classroomsituations ^{(p •}90) . MacP herson (19 91) , whe n describingfeminist ideals and its importanceto nu rsing, cited thephilosophy offemi n i s t Lee Bartley (1977):

TO be a feminist , one firs t has to becomeone througha profoundpersonal transformation.The feminis t change s be ha viorandchangesconsciousness. She seesa new

"s oci a l reality" as the sc a les fallfrom her eyes. She sees how womenare oppressed in the family, inth e work p l a c ean d in society. Through this understanding, i t ispo s s ible for he rtowork wit hotherwome n for libera t ion (pp.22-23).

CriticalSocialTheory

Some nursingtheorists are now espousingtheus e of critical socialtheo r y, to challenge the historical, social

22 and political ideologies of western societywh i c h nursing education has traditionally reflected (Allen, 1990; Wilson- Thomas, 1995; Harden, 1996; Duffy&Scott, 1998).

Allen (1990) described how traditional nursing education has ignored the needs and goals of students, and claimed that critical theory must be used to create autonomous, responsible nurses.Allen (1990) described critical theory as "a theory of social rationality, of how communities or groups make rational decisions" (p.72). In order to maximize rationality, critical theory identifies two principles that must guide interaction- autonomy and responsibility (Allen, 1990). According to Allen, autonomy should guide the person to speak without internal or external constraints, and responsibility should guide the person to allow others to speak with the same autonomy.

Wilson-Thomas (1995) described critical social theory as the means of making explicitthe underlying problems that have continued to haunt nursing,such as oppressive work conditions and lack of autonomy.According to Wilson-Thomas a strength of critical theory is that it allows one to searchfor uncoerced communication that makes constraints to sol ving problems transparent.

Duffy and Scott (199B) identified two central elements

23 of cr i t ica l theory:reflectio nand corrunun ica t i on .

"Ema n cipa t o r yrefle c t i o nenab l es individual s and groups to examinerules, habits, and traditions that areac c e pt e d un q ue st i o n a b l y ... kn o wl e d g e gained in this way is liberatory for once one iskno wl e dg e ab l e of self as a member of a social system,one can choose to be di ff e re nt" (DuffyI>

Scott, p.185). Theother centraleleme ntof criticaltheory iden tifiedby Ouffy and Scott is that it id e n t if i e s obstaclesto communication.

Harde n (1996) described how ma n y inthe nursing

profess ion fin d the whole concept of oppression difficult to accept , and the sugge s tionof oppressionis oftenmet with ho s t i l it y. Har d e nadvocated critical theoryas a means of enlightenment :

Onlywh en our oppressionaswomen and nurses has been re c o g n i ze d, andacritical consciousnessachiev ed , can true humanistic care be giv en.Thro ug hthe development of emanci pa torynursing actions the professioncan stop colludingwiththe social structures wh i ch keep many peo pl e and groups in oppressi ve condition s (p.32). Thomps on (19 87 ) combi nedcritical socialtheory with radical feminist theo ryas a mea ns to critique sources of powe r and domi n a t i o n in nursing.Thompsonfelt that there

24 was a need for critical scholars in nursing to present a systematic and thorough critique to uncover the hidden sourcesof "coercion , power, and domination" that are part of nurses' lived experiences.

Au t o nomy - Nursing Literature

Autonomy has beenidentified consistently in the nursing lit e r a t ur e as being an importantpart of nursing care as wel las a necessity in order for nurses to attain professional status (Benner , 198 4 ; Schutzenhofer s Musser, 1994 ; Bouqhn, 1995).Recent researchinto factors enhancing nurse satisfaction has found that nurses value autonomy and are more satisfied with their jobs when they are autonomous in theirpositions (Havens &.Aiken , 1999; Gleason Scott, Sochalski , &Aiken, 1999). Although numerous nursing authorsand theoristsha v e addressed the issue of autonomy , the nursing research on autonomyis surprisinglyscarce in terms of varietyand methodology, as well as being inconsistent and inconclusive in its findings.

Most of the reported research on autonomy uses quantitative methods and focuses on examining the relationshipsbetweenautonomyand the personal and work- related characteri sticsof nurses and students.

25

personalityconsiderations

The earlier reported research examined the psychological nature of the nursing student and explored the personality traits of those choosing nursing as a career. In the 19605 and 19705 a number of researchers reported that nursing students differed from other college womenby displaying more passive and submissive characteristics, while ranking lower on the characteristics normally associated with autonomy, such as aggression and independence (Heist, 1960;

Reece, 1961; Levitt, Lubin, &Zuckermann, 1962; Bailey&

Claus, 1969). When measuring autonomy those researchersused the Edwards Personal PreferenceSchedule (EPPS) instrument , which was based on male developmentaltheory.

In the 1980s some researchers called into question the previous findings that female nursing students differ in autonomous characteristics from the general population. Kahn

(1980), using the EPPS instrument, found that nursing students did not differ from other college majors. However a limitation of Kahn's study was thatthe non-nursingsample was very small (N= l3).

Till (1980) used the Bern's Sex Role Inventory to compare nursing students to other college students. Items identified

26 asmasculineonthe BernInv entoryaredescriptiveof autonomousbehavior e.g. , independence, as s e rt ive nes s, and self -su f ficiency . Tillfo u ndtha t nursing stu d ent sdid not dif f e r from the gene r a l femal e college students in te rmsof autonomy characte ris tics. Re sultsof Till'5 stud ywere not gene r a l iza b l e, however , becausethe sa mpleused ca mefroma pr ivat e, highlycompetit ive univers itywhich was not reflectiveofmo s t nursi ng student s ' educat i o n.

Theea r l y findingsindicating that nursing students wereless autonomous than other collegestudentswere substa ntiatedlat erby Baughn (1988) wh o use dthe Kurtine s AutonomyScale anda modifiedBe rnSex-Role Inventory Scale to measureautonomy, mascul in ity ,andfeminini ty. Th e Kurtine s AutonomyScale was a scale developedbyW. H.

Kurtine (1974) tha t contained 25tr u e /f a l s equ e st i o n s. High rat i n g s for autonomy on this scale were associatedwi t ha set of factors including achieveme ntorientation, interpersonalaggressive ness , andma s c ul i n i t y. Nurs i n g students in Boughn'sstudy scoredthe lowest in autonomy ch a racter isticsof all colle ge women. In contrast , a further study by Baughn (1992) found that seniornursing students score d as high onautonomy and masculinity as other female collegestudents , whi l e scoring higher on autonomy-rel a ted

27 attitudes and behaviors specificto women.

A study done by Bradham, Dalme, and Thompson (1990) which used the Personality Research Formalso found that nursing students ranked lo w on autonomy. The notionwa s put forth followi ngthe findings of those early studies that nursing attracted individuals,mostly female, who had 000- autonomous personalities.

Schutzenhofer and Musser (1994) used the Personal

Attributes Questionnaire (PAQ) to measure gender-stereotyped personality traits in 542 registered nurses.They found that stereotyped female characteristicsre l a t e d to low levels of autonomy, whilestereotypedmale characteristicssuch as assertiveness were related to high levels of autonomy.

Baughn (1995) sharply criticized the previous research on autonomystating"for the past thirty years researchers have attempted to measure autonomy in nursing students, yet for the most part, the findings reflectneither an accurate nor current profile" {p , 106). Boughn related thisto the fact that many instruments developed to measureautonomy have defined autonomybased on a malemod e l i.e., autonomy through separation and power, and were develo pedusing populations other than nursing students. Drawing on the vo r ks of Gilligan (1982) and Belenk.y, clinchy, Goldberger,

28 andTa r u l e (1985), Baughndevelopedan instrume ntto test au t o nomybas e d ona fema l emod e l, i. e., autonomythrough caring and affiliation.Using this instrument Baughn con du c t ed an experi men ta l study examin ing the au tonomy levelsof students exp o s e d to a femi n i s t orientedwomen ' s healthcours e (thetreat ment) comparedtoa control group . Highly sig nifican t dif fe r e n c e s (p <0.0001) were found betwee n the gr oup sindica tingthat auto nomyrelated attitudesand behavio r s specifictowo men students canbe increased using an experimentaltreatment (Baughn, 1995). A study byCassidyand Oddi (1991) supporte dBaughn ' s

findingsthat auto n omycan be increasedth r o u g h teacher in t erven ti o n. Ca ssidy and Odd i found tha t students who had comple te dan ethics course scored significantlyhigher on both autonomy and rejection of traditional role limitations.

A quantitative studydo ne by Valimak.i et al. (1999), usinga 56-it emLike rt sc a l e questionnaire to measure nursi n g st uden ts' perceptionsof self - dete rmination , questionedwhe the rnursing pr o grams promoteself- determinationorau t o n omy.The findingsof the study by Valimaki et al. indicatedthat nursing students valued self- determination and were willing to exe rcis e self-

determination, but did not feel that theywe r e given the

29 opportunity to influence theirnursing education, norha d they been supported by faculty in exercisingself- determination.

Educational level

Several studies have addressed level of nursing education preparation relatedto the achievementof autonomy but those studies have again been inconsistent in their findings (Alexander,Weisman&Chase, 1982; Murrays Morris, 1982; Perry, 1985; Schutzenhofer &Musser, 1994).

Anumber of studies usingthe Pankra tzand Pankratz (1974) Nursing Attitude Scale (PNAS) have yielded conflicting results. Thisscale conta insthree subsca les:

(1) nurse autonomyand patient advocacy; (2) patient rights;

and (3) rejectionof traditional roles. Alexander , We i s ma n and Chase (1982), using the PNAS, surveyed 789 registered nursesfi n d i ng that baccalaureate education was negatively correlated with autonomy.Considering that this was the opposite result to what was expected, it was suggested that possibly the baccalaureate -preparednurses have higher expectations for autonomy and may feel restricted by their work settings. Incontrast, a study by Murray and Morris

(1982) using the PNAS found increased autonomy in nursing

30 students enrolled in baccalaureate versus diploma students.

A study by Perry (l985) using the E'NAS with a random sample of106registered nurses found a positive correlation between higher levelsof nursing education and levels of autonomy.This scale has been subsequently criticized (Baughn,1995;Wade, 1999) for concurrently measuring inter- related variables and containing severalambiguous items. Its validity in measuring autonomy in nursing students is also questioned asi twas developed for registerednurses and studied registerednurses, not students.

In19 9 4 a comprehensive study by Schutzenhofer and Musser , usingthe Nursing Activity Scale (NAS) with a random sample of 542 registered nurses found no significant relationshi pbetween basicnursing education preparation and mean professionalnurse autonomy scores. The NAS

(Schutzenhofer, 1987) is a th i r t y item scale with five unscored items that serve as measures of internal consistency.The items in the NAS describe clinical nursing situations in which a nurse must exercise some degree of professional autonomy. Although no significant differences were noted with basic education preparation, ANOVAwith post-hocanalysis showed a significantly higher meanNAS score for those with a Master's degree.These results are

31 consistent with other studi esthat indicated a re lat i o n s hi p wi t hadv a ncededuca tion (gradua t e educ ation) and increas ed nurse autonomy (Pankratz &Pankratz, 1974; Collins£.

Henderson, 1991; Cassidy5.Odd!, 19 9 1 ).

Wa d e (1999) sugg estedthat any directrelationsh ip be t we en educ a t i o n level andauto nomymight beobscured, however , by the fact that individuals wi t h higher needs for achievementand autonomyma y se ek higher education.

Nursin g roleconsiderations

Anumbe r of studies hav e reportedsignifica nt differences inautonomy scores dependingon theare aof nursing practice.Schutzenhofer and Musser (1994), using the NAS , fo un d that public health nurses had significan tly higher autonomyscores (t'" 2.79, p'" 0.01) tha n di d hospital- based nur s e s i.e., acute-carecenter nurs es.These findings were consistentwi t h earl ie r studies (Wood , Tiedje, &

Abraham, 1986; Lach, 1992). Although not defined in the literature, i t is probable that pubLic healthnurs eswho are away fromth e constraintsof the institutions and the medi c a l establishmen t haveth e oppor tu n itytopra c t i c e more autonomously.

Hob bsand Yam (1990) (as cited by Schutzenhoferand

32 Musser, 1994) studied a convenience sample of 204 registered nursesin a metropolitanarea, finding that educators and head nurses had signif icantlyhigherscores on the Nursing ActivityScale {NAS) than did staff nurses. Sch u t z e n ho f e r and Musser (1 9 94) found that nurse managers had

significant lyhigherNAS scores than staff nurses (t :5.09, p =0.00 1).The relationship between higher le v e l s of aut onomy and nursing le a d e r s h i p roles was co n s i s t e n t with previousstudies (Pa n kr a t z&Pankratz, 1974;Co llins&

Henderson, 1991 ).

Interestingly, age and numberof yearsof nu r sing experience werere po r t e dby a numberof researchers as having no significant relationship to autonomy (Rhor er, 19 8 9 ; Collins&Henderson, 1991; Schutzenhofer& Musser, 19 9 4).

Adult education- relevanceof autonomy

"Adult education is, by definition, the education of people wh o s e main businessis not learni ngbut Li.vLn q"

(Houl e , 19 92 , p.37 ).Mal colm Knowles (1985 ) statedthatthe adult will learn no matter what.The challenge forthe adult educator is, howeve r, to foster andfa c ilita t e this le a r n i n g.Boththe psychologyandeducat ion lit e r a t u r e is

33 replete with theoriesand evidence addressingthe importan ce of student autonomy inadultle a r n i n g (Kn owl e s , 1980:

Rogers , 19 8 3; Merriam, 1987:).

Me r r i a m (198 7 ) reviewedthe state-of-the-arttheory buildingefforts in adult learni ng and grouped th e attempts at theory building into three categories:"(I lthose that are based on adu lt lea r n e r characteristics; (2) th o s e that emphasizetheadul t's l ife situat ion; and (3) those th a t focus up o ncha n g e s in consci o usness" (p . 197). Me r r i a m found that most of th e theories reviewed ident ified co mp o n e nt s of adult le a r ni n g relat iveto"(1 ) self-direction / aut onomy as a characteris ticor as a goalof adult le a r n i n g; (2) th e re l a tio n s hip of experience, especially those of adult life, to le a rn i n g; (3) the importanceof reflecti on upon one's own le a r ni n g ; and (4) act ionas some sor t of necessary expressionof the learning that has occurred" (p .l 97 ) .

Andra9 0gyand Humanism

The best kn ownthe o r y of adult learning is andragogy definedby Knowles (1 980) as the art and science of helping adults learn. Know les' theoryis basedonfive assumptions, addressing th ech a r ac t e r i s t ics of adult lea r n e r s: (1) adults are more self-directed; (2) adults ha v e a rich reservoir of

34

lif e exper ienc e s, which can serveasa re s o u r c e for learni n g; (3) an adult 's re a d i ne s s to learn is closely associatedwith the developmental tasks of his or hersocial rol e; (4) adultswan t to immediatelyapplyknowledge, soi t mus t bepert inentto the learningand (5) adultsare mo t i va t e d to learnby internalfactors rather tha n external factors (Knowles ,1985).

Ama j o r assu mption unde r l y ingKnowle s' theory of an d ragogy is thatof learner se lf-di r e c t i on. Sel f-d i rection is closelyassociated withthe term autonomy and in some ar easof the literaturehas bee nused synonymously wi t h autonomy.

Self-directed le a r ni ng has been explored extensively in the education literature, and has both advocates and critics.Ac c ord ing toTigh t (1996), the idea of self- directed learning is especially associatedwit h Alan Tough who carriedout many studiesonself-directedlearning during the 1970s. Tough (1979)I drawing on a studyof the learning projects of si xty-sixpeople in Canada, fo un d that 70 pe r c e n t of all learning pr o j e c t s were plannedby the learnersthemselves.

Candy (1991) bel i eve s that the termself-directed can ap plyeitherto the learningor the learner.Candyfeltthat

35 when applied to the learningi tcan be a process used within the learning, and when applied to thele a r ne r i tcan be a personal characteristic or a characteristic with specific meaning for the learning process.Candy stated "A self- directed or autonomous person is able to make a coherent set of beliefs , values and attitudes which include viewingthe self as autonomous" (p , 125).

Brookfield (1993) argued that students must have control over all areas of the educational processifthe ideal of self-direction is to be valued and that this is hard to achieve.Brookfield stated "Who has the final say in framing the range and type of decisions that are to be taken, and in establishing the pace and mechanisms for decision-making, indicateswhere control lies" (p.233).

Knowles (1985) stressed that self-directiondoes not meanisolation, and called for collaboration amongle a r n e r s, teachers and peers. Knowles also noted that although adult learners are self-directed, their education experiences frequently lead to a more dependent stance being taken by them. Grow (1991) pointed out that different learning states require different learning styles and that se1f-directedness needs to be fostered and worked towards by both the student and the teacher. Higgs (1993) also makes it clear that

36 learners need to learn how to learn independently an dth i s requires guidance from a skilled educator.

Ma cKera c her (1996) proposed that "self-directioncan be understood in three ways: (1) as an innatedisposition, trait or characteristic one is born with; (2) as an acquired quality developingnatur allywith increasingage ; and/or (3) as a learnedcharacteristicencouragedthrough educational activities" {p.S1} .

Me r r i a m and Caffarella (1991) described how Knowles ' theory of andragogy and much of the research andwr it i ng on self-directedlearning are grounded in humanistic learning the o r i e s.Humanistictheoryevolved in educationin the 19705 and drew upon the wor ks of humanisticand perceptual ps y ch o l o g i s t s suchas Abraha mMaslow,Arthur Combsand Car l Rogers (Evans &Levine, 1982).

AbrahamMaslow, ama j or force in the foundingof the humanistic pSYChDIDgymo v eme n t; stressed self-actualizatiDn ordeve l op me n t ofthe re a lself (Sahakian , 1976). Maslow believed in a theo ryof intrinsic learning, a process in which one learnsto be a pe r son; learningwhichmu s t not lose sightof the person asa whole; and theexpe ri ence of ac t u a l i zed persons enjoying"p e ak" experiences (Sahakian, 1976).

37 Byrnes (l986) described Arthur Combs vi ew ofma n as

free-willed, motivatedby his perception of himself, andas

an active participant in the learning process.

Rogers (1983) believed that becausei tis theclient who is cognizantofwh a t hurtsand what he experiences , itis necessary for learningto be guided by the client'5 own pe c u lia r experiences. Rogers felt that the goal of humanistic learning, thefu l l y functioning person, can only be met if learning isexpe r ien t i a l, constructedon situat ionsallowing a freedom to learn and on conditions facilitating learning.The elemen ts, which Rogers outlined as bei ng involvedin experi ential learning, included:

(1) i t has a quality of personal involvement ; (2) i tis self-initiatedand even though the impetus may be from the outside, the sense of discovery comes from within : (3) it is pervasive - ma k i n gadiffere ncein the behavior, attitudes and even the personalityof the learner; (4) it is evaluatedby the learner , as the learner can bestdetermine if needs are beingme t; and (5) its essence is meaning, as whenlearning takes place the element of meaningto the learner is built in t o the whole experience {p.20).

Menacke r (l99l) definedhumanisticpsychology as"A

39 psy c holo gy app eali ngmore to the emotions, values, and feelings than the intellect.Its fun d ame nt a l beliefis that humanbe i n g s possess withinthemthe seeds of dev elopmental pe rfectio n thatrequi r enurtu rin gthrough po s i t i ve, punitiveme a ns" (p.7).

Drawi ng onthe works of Maslo w, Combs , Rogers, and Me na c ke r themaj o r tenets of humani stic educationcan be identifi ed as: (1) allas pe ct s ofthete a c h i n g- lea r n i n g proces s mus t emph a s i ze freedom, choice, and autonomyof each individual; (2) learningmust be experiential with active invol vementof the learne r; (3) learning must addr e s sthe dignity and value of the personas awh o l e; (4l learning must enhancethe self-conceptof the learner who is striv ing towards self-actualizationand the fully functioning self:

and (5) evaluationof learningis through self-evaluation by the learner, who alonecanbest findmea n i n g in the learning.

Theoriesbasedonch an ges inconsciousness

Merriam(1987) de s c r i b e d reflection upon the conten t of one'senvironmentand one'sexperiences as a common component of the theoriesof learni ng associatedwi t h changesinconsciousness.Three of the most well-known

39 theorists in this category are Schon, Me z i r ow and freire (Merriam, 1987).

Schon (1987) felt that professional education requires a new epistemology that emphasizes learning by doing, and identifies coaching as the means by which students are introduced into professional practice. Schon described how the student gains professional competencethrough active reflectiononone'5 practicein the contextof this practice. It is in this sense that Schon refers tothe professional as a "reflectivepractitioner". Schon identifies the need for an adaptable professional where there is a process of maturation in whichi tis anticipated that the individual will become increasingly autonomous, self-directedand adaptable and in which critical reflection on personal experiences is a key process facilitating learning.

Mezirow'stheory of perspective transformationwas developed drawing on the works of the German philosopher Habermas (Hart, 1990).Hart in describing Habermas' theory wrote:

Underlying Habermas' extensive body of writing lies a fundamental concernfordominance-free forms of social relations. In particular his ideal of dominance-free

40 communication directly speaks of forms of life which are not power-bound , but which are based on and allow for an authentic consensus among all those concerned about what norms shall guide their practice (p. 127). Mezirow (1981) described three domains of cognitive interest: the technical; the practical; and the emancipatory. The emancipatorydomain is characterized by interest in self-knowledgeand insight gained through reflection andit is the domain that Mezirow equates with perspective transformation.

Mezirow (1981) describes how critically reflecting upon our lives and becoming aware of why we attach the meanings we do to our lives may be the most significant

distinguishing characteristic of adult learning.Mezirow described perspective transformation as "the learning process by which adults come to recognize their culturally induced dependency roles and relationshipsand the reasons for them and take actions to overcome them" {p.7).

Mezirow (1 98 5 ) felt that a significant commitment of adult education is "to help learners make explicit, elaborate, and act upon the assumptions and premises upon which their performance, achievement, and productivity is based" (p , 148).

41 Fr e i r e' s theory emb o di e dthe notion of what he terme d

"c ons c ient isat i o n" whi c hhe def i ned as learni ng to perceive so c i a l, political , an d economic contr a dic tio ns, and to take action against the oppressive elementsof reality.Ac c o r d i ng to Freire (1986) education iseitherfordome s t i c a t i o n or fo r liberation. Frei re eq u a tes domesticat ion withwhat he refersto as theba nki ng model of education. Insuch a model the teacher ma ke s regular deposits of contentintothe minds of thestud e n t s, co rrununicat ion is oneway , andthe educati on experienceis teacher-controllednot student-cente red.

Education for liberation challengesstudents to have power over one'5destiny, to be aut o nomo usassuch (Frei re, 1986). Fre i refostersteachin gpolit ical literac y , anawarene ssof thehi d d e n values of societyand thenhavingthe self - confidence an d knowled ge to seeksolutions.

Relat e d educational literatu re- relevance of autonomy The significance of autonomyto the learn e r has been descri be d no t onlyinthe li t e r a tur e on adult learni ng , but also hasbee n rep orted ashaving a positive impacton lea r n i n g in children, es pe c i a ll y thos e wit h disabilities.

Atermassociatedwi t h autonomyand sometime s substit utedfor' i tis self-determination (Jurchak, 1990;

42 Aike n &.Catalano , 1994).Bucha n an andBro c k (1989) described sel f -determi nationas a person'5 interestin making signi fica nt dec i s i o n s abouthisor herlife. In th earea of ed u c a t i o n promotingself-determi nation has been se en as a stateg y for enhancingeducation. I tisa wa y of promoting in de pe ndencewith the beliefthat self-determinedpeople are more likely to go on toac qui r e the other sk ill sand abilitiesthe y will need in life (Deci, Eghrari , Patr ic k , &.

Leone, 19 9 4; Yost, Shaw, Culle n , &.Bigaj , 1994; Field, 1996;

Morgan, 1996).

Ina study done by Grol nick&.Ryan (1989) students who were encoura gedandsupp orted to be auto nomous bytheir parentsbecame more autonomous in their learning and were able to better integrate the material being taught.

Promotingself-determinat ion inthe learner ha s been found tobe a part i c u l a r ly important strateg y in the ed u c a t i o n of childrenwith learning disabilities

(Brotherson, Cook, Cunconan-Lahr , &:We hme ye r, 1995), high school stud ents wi t h learningdisabilities (Durlak, Rose, &

Bu r s u ck, 1994) , andfo r people withmentalretardation (Wehmeyer&:Metzler, 1995).

The literatureon critical thinkinghighlights the importance of autonomy in developing criticalthinkin g

43

skills. Bandma n and Sandman (1988) cited Seigel 's conceptualization of critica l thinking ineduca t ion as identifyi n gthree impe ratives for teachingcri tical thinking : (1) the facilitation of student'5 self-suffic ie ncy and autonomy; (2) theempo we r ment of studentsto control the i r own desti ny through th e encouragemen t of inquiry , explorationof alter na tives and critical analysis ;and (3) pro mo tingrat i o na l i ty as theuse of rea son. Wo od s (1993) desc ribes the importanceof empowermentinthe dev elopment of criticalthinkingabilities . "Powe r in crit icalthinking gives students the permission they needto thinkabout and explore new ideas" (Woods , 1993, p. 75).

Summary

The re vi e w of the literatur eindicates that autonomy is highlydesiredby nursesbut continues to ev ad e nurses both in practice and educa tion set t i ng s. Th e importanceof autonomyto learninghas been addressed extensivelyin the education literature and is a ke y compone ntof adult learn ing th eo r i e s . Theoppressi v e nessof authoritarian practices in nursing education has be en addr essed by a number of authorsindicatingthatnursingstudents experience little autonomyduring th e ir education

"

experiences. Surprisingly, there has been little re s e a r c h in nursing exploring in an in-depthma nnerfa c t o r s that enhance or limi tautonomyin nursing students. I found no published qualitative studies related to nursing students and how they perceive orachieveautonomy.

However, qualitative studieshave been used extensively and effectively in exploringnursing students' experiences of "caring" (Halldorsdottir, 1990; Beck, 1991; Kozowski, 1995) .

Research Questions

Kennedy, Janes and Kerr (1995) described how the literature review provides the foundation for the study and can contribute to formulating the research problemand subsequently influence the selectionof the methodology. The literature review did influencemy choice of research questions and the methodology that I chose for this study, through heightening my awareness of what we needed tokno w about this issue and how I might best approach finding the answers.The research questions th a t guided my study were:

(1) How do female nursing students experience autonomy?

(2 ) Arenu r s i ngeduca t i o nexp eri e nces enhanc ing aut o nomyinfemal e nur s ingst uden ts or perpetuat ingoppressi o n ?

(3) What role do nurse educators play in the female nu r s i ng student' 5ab i l i t yto achieveautonomy?

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46

CHAPTER THREE

Methodologyof the Study

Rationale for methodology

A critica l feminist approach using qualitative methods was consi dere dto be the most effectiveapproach to ach ieve the purpo s eof this study.

Wil s o n-Th oma s (199 5 ) descri bedcritical social theory as "an approachfo r crit iquingexistingconditions for the purposeof enhancingindividualautonomyand responsibility, and liberatingindividuals from conscious and unconscious restraints" (p.572 l.Wils o n-Thoma s fe lt that, in order for nursingto achieve itsgoal of autonomy, theories must be predicated on researchtha t makes assumptionsabout in d i v idu a l s andgroups transparent.A critical approach for this study was impo r tant in understanding the relations amongst knowledge , power, and forms of dominationwithin nursing edu c at i o n programs such tha t transformationcan be achieved . Critical theory is howeverthe product of the pro ce s s of critiquerather th a n an actual r e ee a r c n>

me t h od o l o g y (Doyle, 1995). According to Habermas (cit e d by Har de n, 19 9 6) social critiquemu s t be be aimedat the

47 fundamentalstructures and ideologies of social systems. Two of these fundamental structures are the kinds of work available and the imagesof women, bothof whichwe r e key factors in this research.

Lukeand Gore (1992) defined feminism as the pursuit of autonomy for women.Sigsworth (1995) points out that

"feminist research is overt in its value position of attempting to reli evewomen'soppression" (p,898). King

(1994) stated "afe mi n i s t methodology refers to research questions that are pertinent to women, are of intere stto wome n , and are developed out of political struggles" (p.20). Application of a feminist methodology when exploring how female nursing students experience autonomy was therefore very appropriate to this situation. King further described a feminist methodology as emphasizinga non -hierarchichal , reflexive and interactive approach aimed at empower mentand transformation . E:pistemologicalissues underlying the feminist research process include the idea that women's experiences can be legitimate sources of knowledge and that women are "knowers" (Sigsworth, 1995). Therefore this implies that subjective knowledge is valid and" informants are experts on the i r lives" (Stanley&Wise, cited by Sigsworth, 1995).

Considering that the purpose of this study was to explore, describe and understand the experiences of the participants in relation to autonomy, qualitative methods were used. Kennedy, Janes and Kerr (1995) described how epistemologically the qualitative researcher values personal knowing, and accepts that valuable knowledge comes from the participants who expressed it in their own words.

Ontologically "the researcher's role is to understand and interpret, through indepth exploration within the setting, how the participants construct the world around them"

(Kennedy et a L. , p.8).

Fetterman (1989} described how the qualitative researcher must strive to look at and appreciate the setting from the perspective of the persons within it. The fact that I am a nursing instructor and an insider, as such, enhanced my ability to critically analyze what the participants were telling me. Doyle (1995) stated "If improvements, changes or transformation are the real goals of educational research, then i t follows that the people most involved with the situation are in the best position to understand the practical realities of schooling" (p. 5).

By combining a critical feminist approach with qualitative methods I was able to answer my research

"

questions, dig beneath the surfaces and peel backthe layers to describe and understandhow nursing students expe rience autonomy.

Thepa r t i c i p a n t s

In accordance with a qualitative research design a purposivesamplingprocedurewas usedto obtain information - richcases. In St. John's th e r e were th r ee diploma-nursing programs that were phased out at the end of 1998. There was also a baccalaureate-nursi ng program that was phased out in 1999.Two othergr o u p s of students are presently enrolled in the new collaborative nursing education program. The nurse ed u c a t o r s for the old and new nu r s ing programs havenot changed. tormy study I chose participants who had recently complet eda diplomaor baccalaureate program. The criteria for selection included (a) be female; and (b) havegraduated in 1997 or19 98 froman undergraduate nursing program.

I limitedth i s studyto th e fe ma l e gender as I fe l t that be c a u s e of previoussocializatio n there might be differences in how females andmales exper ienceautonomy, a situation that is beyond the scopeof this research.My focus was on the commonalties exp eriencedby females, not the differences between females and males.I chose recentgraduates as they

50 should no longer feel constrained by the educational institution , yet still ha v e vivid experiences to relateand ther e forebean informatio n -richsource of data. Fromthis group of graduatesI selectedtwo to thre e fe malegraduates fromea c h of the four schools of nursingfor a total of ten partic i pants.The participants ra ng e d in age from 24 to 39 and each had between one and two years nur s i n g ex perience . Seven participants had graduat ed from diplomaprog ramsand three from a degree program.

Data collection

Data collectionconsisted of indepth face to face interviews wi t hthe participants , each lasting fromone to two hours. The purpose of the interview was to understand share dmeaningsbydrawingfrom the partic ipantsa vivid pictur eof their experience, compl e t e withthe richness of detail and context that shapedtheex pe ri e n ce (Sorre ll&

Redmond, 1995).The interviews were of a semi-structur ed open-endedformat, with the focusbeing on engaging the participant s inth e process of telling theirstories. Because the part icipan ts' st or ies structured th e interview (as suggested by Sorrel l and Redmond) I providedthe part i cipantswithsome introductoryma t e r i al prior toth e

Sl inte r vi e w so thatthey could come tothe interviewwit hrich narratives to tell. I discussed brieflyby phone the nature of the interview witheach of the partic ipants. It was during this contact that I began to realize that autonomy was an unfamiliar concept to the participants.An intervi ew guide (AppendixA) was used when necessary duringthe

interview process .

Vital to the interviewprocesswa s being able to get theparticipants to express theirexp e r i e nc e s. Inaccordance withfeministmethodologyi twas important to maintain a non-hie rarchicalapproach , and display to thepar t i c i p a n t s thatI trulyvaluedwhat they had to say and what they have experienced . It was also important to have the participants fully explore the circumstances surrounding their experiences, and to continue to request further information until the participantcould not recall any further details.

Using a reflectivedialecticte c h n i q ue , I discussed and verified input during the interviews and asked for clarification wh e n necessary. I had to conscientiously avoid suggestive and leading questions so that the experience

"remainedthat of the participant" and not whatI might be expecting. Anderson (1989) points out that it is important that critical researchers "a t t e mp t to ensure tha t