Yasmin Lilla Veronica BujdosoI; Amélia CohnII
IPrograma de Pós-graduação da Faculdade de Medicina (FM). Universidade de São Paulo (USP). São Paulo, SP, Brasil
IIDepartamento de Medicina Preventiva. FM/USP. São Paulo, SP, Brasil
OBJECTIVE: To assess the main signs of stress, coping and stressors of nursing Master's students, and the process of writing their dissertation with professional insertion.
METHODOLOGICAL PROCEDURES: A explorative qualitative research of thematic analysis was conducted using individual interviews. The convenience sample comprised 18 Master's students and six tutors of a university in the State of São Paulo, in 2004.
ANALYSIS OF RESULTS: Although the course was stressful at times, Master's students considered the study as an opportunity to leave care and start teaching. The most satisfying aspect of the post graduation course was to be in an environment where professional issues were reflected upon reinforcing the view of Master degree as an escape and a search for support. The Master's degree was seen by nurses as the legitimization of knowledge to be professionally recognized. That does not occur in care, where they feel neglected, and probably from this context there is this need of "escaping" from the hospital.
CONCLUSIONS: For nursing Master's students, the Master's course was less stressful than their professional activities, and it was a way of coping, escaping, and looking for support to deal with care.
Descriptors: Students. Stress, Psychological. Dissertations, Academic. Qualitative Research. Health Postgraduate Programs.
Research on stress and coping strategies are mainly quantitative, where standard questionnaires are applied, making it difficult to analyze subjectivity specificities of the different individuals due to the limitations of this kind of instrument. Indeed, Laurell & Noriega12 (1989) highlighted that the theoretical methodological approach should be selected when researchers face problems requiring new designs, different from the dominant way of classifying them.
Among several issues relevant for future research on stress, Dewe et al9 (1993) point out the need for assessing the meaning individuals give to events they are submitted, however, it is not specified which categories are representative of subjectivity in this process. Pearlin18 (1986) underlines the need for no longer searching for specific causes of stress, since it is a process related to different roles individuals play in society. On the other hand, people with similar life experiences are not equally affected by stressors, probably because of their different ways of coping. According to Newton,17 (1989) qualitative research must be developed to investigate stress and coping, instead of just rereading the already existing quantitative methods.
There is excessive concern with classification and specialization of quantitative instruments assessing stress and coping, distancing the apprehension of the process. Stress sources may come from the external environment, such as violence; from work, such as the fear of losing the job; or from more generic threats such as economic recession. However, less stressing experiences present in quotidian life lead to chronic stress and constant tensions, demanding individuals to adjust to them.
Nurses professionalization is characterized by difficulty to define institutional space of their functions, and consequently appropriation of their idealized work objectcare, reflecting in the research object of nursing Master's students, and dissertations could be a search for answers on how to deal with occupational difficulties.
Authors such as Silva20 (1986) explain certain aspects of the profession and indicate the difficulty in delimiting nursing functions which may reflect on the choice of theme and in the dissertations' development. This problematic contributes to select nursing Master's student as the subject of the present research.
Analyzing recent research on nurses education, Chirelli & Mishima7 (2004), among others, evidenced that nursing education still emphasizes the technical dimension, and there is a conflict among values, knowledge, and care. These professionals also deal with a rupture of the care meaning, since their function is not clear, as documented by previous research, such as that of Silva20 (1986). Research professors, such as Mendes13 (1991), also discussed the teaching and practice dichotomy.
This is a complex problematic linked with nursing professionals as graduate students and relates to the quality of academic production, the think tank formation, the effective vocation of the graduate course in the education of researchers the greater professional qualification, and technical, economic, political, ideological and cultural factors these issues are not exhausted by the present study.
The objective of the study was to analyze correlation between the main signs of stress, coping and stressors of nursing Master's students relating their dissertation development process to their professional insertion.
The research was conducted in a nursing school of a university in the State of São Paulo. Field work consisted of exploratory research with qualitative approach, applying, for data collection, semi-structured recorded individual interviews with 18 Master's students starting the course in 2001, 2002 and 2003 and six advisors of each of the six concentration areas of the unit: nursing service management, obstetric and neonate nursing, pediatric nursing, psychiatric nursing, collective health nursing and adult health nursing.
A convenience sample was built by interviewing Master's students in different phases of their master course.
Thematic analysis guided the collection and organization of the material.
Subjective academic and professional aspects of Master's students' work were investigated, since the object of the dissertation and work are related, leading to conflicts both due to proximity and to distance.
The research has been approved by the Research Ethical Committee of the Faculdade de Medicina and of the Faculdade de Enfermagem at the Universidade de São Paulo.
ANALYSIS OF RESULTS
Speeches presented are from Master's students (M) and advisors (A).
Most Master's students had just graduated from public institutions; they had specialization and thought about undertaking the Master after undergraduation; they worked in hospitals, and intended to get a scholarship and study only. However, frequently, the impossibility of keeping only with the scholarship was emphasized.
"I cannot quit my job, also because I do not have a scholarship and I cannot have a scholarship either because I have a formal job, and even with the scholarship [it is] (...) symbolic because (...) it is ridiculous (...) how come they give such scholarship!" (M)
Advisors were chosen according to their research line Master's students changed their object and methodology in their dissertations to fit advisors. When work and study object were too close, there was a concern in not obtaining a critical distance. On the other hand, they acknowledged that this made dissertations easier since the questioning came from an issue of the every day work.
"It was linked, and very important, because I worked in what I was studying" (M)
When there was distance from the study object, designing the problem and developing dissertations were confusing. Although Master's students were frustrated because they could not develop the theme they had proposed, they were resigned to following the advisors research line.
"The advisor you get will define your pre-project (...) the research line is [theme] I had to adhere to her research line" (M)
Regarding Master's students choice of research object, there is the need to match internal and external demands (Bourdieu2 2004), and not considering the correlation between individuals and their job might be dangerous for the mental health (Dejours8 1999). However, the commitments and enrolments needed to become a researcher must be considered (Kuhn11 2003), as well as the organizational aspects (Giannotti10 1987).
According to Giannotti,10 (1987) just as the paradigm of handmade work is gradually lost, the practice of science is more than just knowing, and designing a view addressing part of the reality, resulting from a contemplating standpoint. This practice results from an organization that encompasses researchers, employees, hindered by an extraordinary infra-structure, where individuals are replaceable, therefore losing with it, the intimate bond that connected the maker of the problem and the solution.
The problematic of fitting the object, also refers to the excessive division of the issue and its bibliographic delimitation linked with groups,11 hierarchization of the objects into legitimate or not,2 and their commitment with historically built interests,15 making the thesis a reproduction of research already conducted,4,22 due to the students' lack of autonomy.2,7,22
Relation between teaching and research is subjected to its assumed inseparability (Chauí7 2001; Giannotti10 1987) as well as the tension between under-graduation and graduation, i.e., between teaching and research (Buarque4 1994; Santos19 2003). Buarque4 (1994) described graduation as the University's best place for reflecting new ideas, as it is a privileged center of research production. However, graduation in Brazil instead of becoming a formal teaching program, became a way to make up for deficiencies in under-graduation, resembling more a University course than an advanced center of knowledge and thinking.4
Master's students sought advisors approximately one year before enrollment to prepare their pre-project, so that they are ready for the qualification test, since they have only 30 months to conclude dissertation. Graduation evaluation agencies pressure was a concern for advisors, who considered that this deadline compromised the whole dissertation development; there was concern in selecting Master's students that could finish their dissertation on timely and not to waste their time.
"I was more careful, about one year before I sought the professor and presented my project". (M)
The relation with advisor was ambivalent: Master's students felt pressured by advisors and, at the same time, they expected advisors to be always available, even when they did not meet a deadline, such as file for the qualification test, file for a Research Ethical Committee, or submit their dissertation. Advisors preferred younger Master's students with previous experience in research during undergraduation; however, they did not deny access to older ones, with greater experience of life, but who also presented difficulties to deal with the methodological aspects. Concern with quality of work was more evident in reports of advisors, that referred the Master's students had greater concern with the usefulness of their Master for their professional practice of nursing.
"There is no point doing just something (...) we do not feel good with ourselves (...) they are not concerned with quality, the main concern with quality comes from the advisor". (A)
There were several academic issues involved in the process of designing dissertations, such as the concern with conciliating the practical field with the knowledge gained from the theoretical field.
"There are things you learn here that unfortunately you cannot put into practice outside which is your field (...) and it is sad that everything occurs only within the university, for a small number of people, and we do not reach those who are in fact our study object". (M)
Difficulty to conciliate practice with theory is an issue raised in research with nursing graduates (Ax & Kincade1 2001; Chirelli & Mishima7 2004). Some advisors interviewed said they considered, as much as possible, incorporating questions from the works developed in the Master's course as a way to look for answers to the occupational conflicts faced by Master's students. One of the advisors was emphatic when indicating the limitations imposed by the research line to dissertations themes which makes it impossible for Master's students to study a personal work issue.
Despite most Master's students reported that the reason for taking the Master was to lecture; advisors described graduation as essentially teaching research rather than just lecturing, although they acknowledged the need for universities to be closer to care.
"Masters are a little far from teaching; teaching is quite unsatisfactory, almost nothing, they end up thinking that being a Master is doing research". (A)
Graduation was felt by Master's students as a way for being valued by their work team and by other health professionals, especially physicians. They believed that acquiring knowledge through the Masters was a way of becoming more powerful, because they felt that submission and obedience were issues present in the work reality.
"Nursing is little recognized, and there is also the stigma that (...) we obey physicians, and we are in the same level, the difference is that we studied nursing and they studied medicine; I believe that when one starts to (...) develop an academic life, that will bring greater recognition". (M)
Knowledge is a way to obtain more power (Bourdieu3 2001; Castellanos5 1988; Nakamae16 1987). Researchers must interfere in the political world, because their social authority is due to their supposed respect by the "unwritten moral laws", and to their technical competence; they are intellectual people essential to the social struggle, considering totally new forms of domination (Bourdieu3 2001). For nurses, the research process leads to questioning the reality they are inserted in and the knowledge from this questioning gives them a new power that affects the balance of the forces at stake (Nakamae16 1987).
Regarding medical hegemony, health practices contributed for reproducing social structures. Appropriation of knowledge restricted to hierarchically superior agents selectively chosen by universities and the corporate regulations that prohibits the performance of several activities by unskilled agents perpetuate in society the inferior position of women compared to men, and of nurses compared to physicians (Castellanos5 1988).
Master's students in their care practice took up the role of intellectual nursing workers, since they took chief or supervising positions in public and private hospitals, and those who were part of public institutions performed specific health programs with manager position (Centros de Atenção Psicossocial, Programa de Saúde da Família Psychosocial Health Center, Family Health Program). However, Master's students considered the profession associated with hospitals and those who worked there said they had no option and waited for a position in lecturing. The Master enabled them to lecture and leave the hospital. Those starting Master course immediately after under-graduation, saw study as an opportunity not to work in hospitals; the same thing occurred to those working in non-hospital institutions.
"In two years I want to leave hospital and only lecture" . (M)
The Medical-hospital model does not encourage either nurses' authority or autonomy to reflect upon the intention of their actions, and the content of the "technical scientific base" that guides them, since they affect type, content and purposes of their interventions. However, because they needed to be considered as "rational beings" and as such, being able to create and to "self develop", they end up reflecting on themselves and on their acts. (Castellanos5 1988).
Issues regarding conflicts of the profession influenced the dissertation process. Master's students and advisors reported nurses marked characteristics that they believed were reproduced in university. Master's students and advisors saw nurses as authoritarian, altruistic, practical, systematic, who followed rules, and this image was in agreement with the literature (Castellanos5 1987; Mendes Gonçalves14 1994), they are systematic and authoritarian (Mendes Gonçalves14 1994) they search for autonomy (Castellanos5 1987; Nakamae16 1987).
"The behavior of nurses is not very flexible, they are strict, conservative (...) they have to do practical things (...) they are very authoritarian" (M)
The main signs of psychological stress in Master's students recorded by advisors were anxiety, insomnia (or less frequently, excessive drowsiness), nervousness (feeling upset and fights), fear and instability, blocks (forgetting words and diffusion), change in voice (stumbling for words, lump in the throat, stuttering), being worn out, depression and change in mood.
Signs of physical stress were: tachycardia (or crushing pain in the chest), digestive problems (gastritis, stomach ache), tension (body aches), change in weight (more frequently gain weight or lose weight), headache or migraine, changes in period, or hormonal problems, sweating, weakened immune system (frequent flue), and somatization (spots on the body, formication).
Main signs of Master's students coping strategies reported by advisors were: flight mechanisms, seeking for support, rationalization or planning, emotional discharge (especially crying), eating excessively, practicing other activities and seeing the Master conclusion as a challenge.
The process of designing the dissertation had as its main stressors conciliating the Master, work, home, and personal life, and also dealing with the conclusion deadline.
"It was hard because of the time (...) working (...) I had two bosses, (...) I did not have personal or social life, only with my partner (...) I did not go to anyone' s birthday (...) you cannot be in two places at the same time". (M)
Anxiety is the most commonly found sign of psychological stress in surveys with nursing graduates.1 Dealing with time and deadline is the most commonly found stressor, both in surveys with nursing under-graduates (Ax & Kincade1), and in surveys with nurses (Silva & Bianchi21 1992), reinforcing the findings of this research.
Considering the most pleasant aspects, highlights were recognition of Master as an arena for discussion. seeking support to deal with work issues and a flight when they reported about "inside" and "outside" the university, the "inside" protected them from the "outside", reinforcing the perspective that the option for a Master is a coping strategy that facilitates to lecture and therefore, being free from working in hospitals.
"It is an escape, I end up throwing everything on the school it is the day that I arrive and sleep on the chair, talk back, it is where a loose myself". (M)
Nursing Master's students did not have the purpose of their academic work clearly defined; they did not know what their ideal occupation was if nurse, researcher, or professor - what was the use of their research to nursing practice, despite their concern with this aspect and what changes it will bring to their lives.
For nursing Master's students, the Master was less stressful than work, and studying consisted of flight and seeking support to deal with care. The Master was a place where their knowledge and intellectual work was made legitimate, and it was where they could achieve the recognition that they could not find in care, where they felt depreciated. This context probably led to their need for "escaping" from hospital.
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Yasmin Lilla Veronica Bujdoso
Departamento de Medicina Preventiva
Faculdade de Medicina da Universidade de São Paulo
Av. Dr. Arnaldo 455, 2º andar
01246-903 São Paulo, SP, Brasil
Article based on the master's dissertation by YLV Bujdoso presented to the Preventive Medicine Department at Faculdade de Medicina of Universidade de São Paulo, in 2005.