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Abstract

This paper aims at making visible the secondary socialization process undergone by the novice -I our case the nursing student- who begins to work for a health care institution. We have used confessional accounts written by the students during the first 20 days of work in the hospital, i.e., during the process of introduction in the setting. In addition to the cultural shock and alienation, it has also been observed  that the student's role corresponds to a transitory discrepant role (Goffman, 1959) characterized by invisibility, liminality and the non-existence as a person. The social configuration of the non-being in the hospital scenario is provided with an eccentric subjective realism, which is extremely stressing and with a strong emotional impact. The experiences of the student are supportive evidence.

Introduction

Pedagogy of demotivation can be considered as a study of sincerity. Part of this study was presented to an examination board some years ago so as to obtain the Diploma de Estudios Avanzados (Diploma of Advanced Studies). While it was being evaluated, the members of the examination board said it was a nihilistic study. They pointed out that people who go onto a new social stage, see themselves the way the title of this study says. That means that it is common to be considered useless or just a nuisance.

In all sincerity, I do not think that it is true and I just want everybody to think about their own personal experience to express their opinion. Nihilism is seen as pessimistic. This study does not talk about pessimism, but it describes and interprets events full of meaning that happen in everyday life. It is not a pessimistic study, even though it focuses mainly on dramatic and implicit aspects we do not usually talk about. Students may experience a feeling of emptiness and pessimism: they feel alienated. That is what readers may notice, an existential desperation expressed by words. As a researcher, and also because we are talking about a qualitative study, I am not going to hide any information or any word and its meaning, I am going to show the real feelings and perceptions of the informants.

Therefore, the aim of the study is to describe and to interpret the start of the students of nursing in hospital from the point of view of the informer. I think, and that is much more than just my opinion, that this experience shapes the personality of a professional role. It is worrying that a discipline which defines itself as holistic initiates its future members from the depersonalization.

Participants and methods

Collecting information. Some ethnographic strategies were used to collect information (Taylor and Bogdan, 1984; Goetz and LeCompte, 1988). Participants were asked to write a field journal where they had to write about their personal experiences during their first twenty days at the hospital. The narrative style resulted to be denominational, which means that the story is told in first person and that we can see the point of view of the teller, his thoughts and his feelings but there are some real descriptions as well.

Participants. People who wrote about their experiences were all first year students of nursing -year 2003- without previous experience in any hospitalization unit. Sixty five out of the eighty registered students met this requirement. 65 manuscripts between 5.000 and 27.000 words were written.

Social stage. The hospitals of the public health care service of the city of Jaén and Linares where the places where the study was carried out. During their training period, participants were in different units of all those hospitals: Neurotraumatológico, Materno-Infantil, Medicoquirúrgico, Doctor Sagaz, Residencia de Santa Teresa, Crónicos Orgánicos and San Agustín de Linares.

Analysis and interpretation. The aim of the analytical process is the search for sense. That is why the stories were divided into several parts which were again divided into propositions which were finally divided into small units.

From a descriptive-chronological point of view, it was carried out in two different stages: a more general one and a more specific one. The first and more general stage included two parts (Taylor and Bodgan, 1984; Amezcua and Gálvez, 2002): (1) a previous reading of 10 field journals for a first approach to the stories and (2) a reading of every journal and a later analytical report on the subjects they deal with. Some notes were also taken. The more specific phase was about the analysis of two main subjects: the perception of the way they were treated and the feelings expressed at the beginning of their training period. The analysis of those subjects was carried out into these stages: (3) checking of the analytical report to point out the main subjects (4) pointing out and transcribing parts of the text and propositions related to the main topics, (5) classification of the propositions, (6) reduction of the propositions and classification into categories, (7) comparison between the information and categories with theoretical concepts of the social sciences (Sociology, Anthropology and Philosophy) and (8) writing of a significant report about the feelings of the informants and their perception when considering the way they were treated during their training period.

Findings and discussion

Initial situation and utopia. We can talk about two main characteristic of our informants that have to do with their inexperience concerning the social scene in the health service. Those are the cultural clash and the feeling of being apart. The cultural clash is the confrontation between the inexperienced person and the new and bizarre culture that that they find themselves in (Hammersley and Atkinson, 1983; Amezcua, 2000). Students feel confused because of the utopian thoughts that made them study nursing, the feeling of happiness before confronting the real situation at hospitals and the reality they face daily.

Feeling distant is the result of the lack of familiarity with the new culture. Students see everything that happens on the stage but they do not feel they have a role to play. When talking about an ethnographic study, the cultural clash as well as the lack of familiarity make it possible to look at the daily life with a certain "scientific" distance and with more realism than that of the actors involved, whether they are patients or professionals, who are too accustomed to the daily routine to perceive dissident facts or to question everything that happens daily.

Students have a privileged position. On one side, they have the status of a full participant and his positive qualities (Hammersley and Atkinson, 1983): they are considered to be member of the scene, they get internal knowledge and they gain access to some information and places restricted to the members of the institution. Unlike the ethnographer that plays this role when carrying out research, students do not need to disguise themselves or to deceive anybody because thanks to their role they acquire these qualities temporary until they come members of the group or until they feel identified with the culture or with the values of the institution. That situation makes it possible for them not to feel different. That can happen in a week, in a month or it can simply never be like that; for example, a student told me one month after she finished her training period that she did not agree with the reflection and opinions written down in her journal because now she had a different perspective of things.

On the other side, the status of students has similar characteristics to that of the total observer (Hammersley and Atkinson, 1983). The internal position of students can be compared to that of an observer that describes from a window what it is happening on a crowded street. The observer might see a mugging and without any involvement he might also describe the way people and the mugger react. Students do the same when looking at what it is happening without any involvement and they see everything because they lean on a window which allows them to look at the scene. That is the role of the students when a cardiorespiratory arrest happens or when a patient dies. They do not have the authority to act and nobody relies on them because they simply do not exist in those circumstances, so that we have a very emotional situation of unidirectional observation. This situation where the observer plays a predominant role is very common.

All these qualities define a very special and privileged status to describe hospitals with interpretative naivety and vivid purity. Students do not see themselves as researchers, they hide behind their white clothes that allow them to have access to the stage. Their presence does not cause rejection and it does not affect the way other actors play their roles because they are used to having students during their training period. Even without realizing, students have access to internal information and they describe the hospital world from an emotional intensity of great commitment and involvement.

The tribute of a privileged position. From one day to the next, students, who do not know anything about hospitals, become members of the health institution able to gain access to the scenic background. This privilege has a price.

What a social researcher considers to be a privileged situation for the ethnographic research and social interaction on the stage, is considered to be a dreadful experience by students. The health institution is the product of its history and it has some rules to control human behavior. Students begin their activity in this field without a institutionalized activity. They come onto the stage but they do not know anything about its history and its control mechanism. Without knowing it, the first experience they suffer from is the initiation to the institutional order and the submission to its historicity. That is why they feel controlled by sanctions and coercive measures which teach them to behave the way experienced people are supposed to behave. The first weeks of the training period can be compared to a socialization program, they help to adjust the unpredictable behavior of the students to the predictable and controlled behavior that the institution expects from them.

It is necessary to understand that the institution is not something abstract, quite the opposite, it is something specific that materializes in the social relationship between people and groups which define the hospital hierarchy. The institutionalized groups living inside -nurses, nursind assistants, orderlies, cleaners, doctors, patients, relatives, students from more advanced courses- are responsible for showing the adecuate behavior and the negentropic and logical order of the institutional thinking to the new student.

One of the most powerful coercive mechanism to modify behavior consist of reducing the human wish of a person until it disappears and doing that means destroying that person. The despersonalization process is painful and students shout in order to survive, they complain and call for justice, they also rebel against the institutional thinking, but it is too strong to withstand. They become depressed and it is difficult for them to get to sleep and to understand what it is happening around them. They say: Did I make a bad choice?

How can personal wish be reduced to institutional wish? We have found several mechanisms, but we will just have a look to one of them, the experience of not being or how to become invisible. Students express that with three different kind of propositions starting by: "They call me [...]", "I feel [...]" and I am treated [...]".

My name through the others. Before arriving in hospital, the students had a name which identified them and made them different considering social interaction. They also had a particular way of dressing which made them feel identified with a group and with a social class. When arriving in hospital, this identity disappears. The name is replaced by a lot of different names which leads to anonymity, the way of dressing has also to do with that: a sort of white pyjamas whith a label which shows in big letters that they are training nurses.

There are some explicit and contextual denominations, so that some students are considered to be "pretty", "girls", "useless", "hopeless and chicken" by some professionals. For some patients and their relatives they are just "little dolls" and "little girls" and in some specific cases, when dealing with patients with mental disorders, they are called "bitch".

There are also some patients that say to the student "you are nobody here" or "you don't know".Students are considered by some professionals as "useless help" or simply "first year students". Even a doctor said "What's that?" when referring to the students. The conclusion written in the field journal of a student saying that after a month of training period nobody knew her name is also quite surprising.

What is the student? What hides behind these words? It is simply the feeling of those people who feel they do not exist in certain contexts. The labels addressed to the students place them in the limit between people and objects.

People who do not exist go unnoticed: the way vassals are treated. How do experienced staff and training doctors treat students? It is obvious that the way they are treated is something which hides behind the names that institutionalized actors use to address to them. Professionals call them "stupid" because "they ask them to be quiet with aggressive words because they are the bosses" and if the student "says he knows how to do it, they ask them in a bad way" or "they send them on an errand so as to keep them happy as if they were children", they tell them off using bad excuses such as that they have spent more time than expected in the ward with the patient, they are treated as "empty sacks" where useless things are thrown away because they do not want students to learn but to do what they are asked. The student is a "lapdog" whose answer is "Yes, sir, what would you like?", beginners, students of the first year of nursing and privates do not think, they just obey.

Some patients address to students as if they were servants: "comb my hair, do that this way because I know more than you". They even shout at them because of problems which do not have to do with students -e.g., a diet having some food the patient does not like-, they ask students to buy things in the bar or they keep asking them so as to question their professional competence, above all when talking about young patients. Some relatives accompanying patients are rude to them because they want students to do everything they ask them, they refer to them as "swines" and even students of higher courses push them around.

But there are some more humiliating ways considering manners: a implicit certainty of being nobody. Students say that they are not paid attention and that people ignore them, they do not talk to them, they are not interested in them, they do not know their names, they do not look at their faces, they do not ask their questions and when they do, they do not show interest at all, they do not even answer when students say good morning to them. The situation is so devastating that a student wrote that she preferred to be told off rather than be ignored, as it was the case.

The treatment students receive goes from humiliation and shame to a feeling of isolation and invisibility. But, how do students feel being treated this way?

Making students feel useless. Students use field journals to describe how they feel. In order to point out the parts of the text that deal with feelings, you just have to find sentences starting with "I feel" or sentences answering to this question: "How does the student feel?".

The first day of the training period at hospital students describe the way they experience fear, uncertainty and stress and it is a common feeling which can be explained by the fact that they are facing a new situation. There are some feelings which also come out but not during the first days of the training period, so that they are not the result of being scared because of facing a situation for the first time, they are the result of social interaction with the groups of the institution.

Professionals, patients and people accompanying relatives let students know that they are a "nuisance", they make them feel useless, "a servant", "a maid" or " a receptionist". Students are the "shadow" of professionals, "something useless", the feel like "a yolk", "a checker", "a goat in a garage", "wally", "without having any clout", "the stupid of the shift".

This situation makes students feel useless, they feel they are not needed, they think they are nobody. Even other actors playing a less important role on the stage, such as the relatives of the patients have this feeling (Flores and colls. 2000, 2002). They think again whether they made a good choice when they decided to study nursing or not. They do not even know whether the situation they are experiencing is real or not. Some of them feel helpless and it makes them feel very sad and even cry.

Empirical information sheds some light on the reasons why students feel reviled. They feel bad because they cannot act independently, because they have to obey orders given by everyone- from the cleaner to students of higher courses- and a lot of people look down on them because they are never in the right place- it is true that they do not have any place-, because nobody is interested in knowing their names. Even if students think that professionals are not doing well they do not say anything to them because they need everyone's help so as to know what they have or what they can do, because they keep asking everything, because they feel insulted, because people do not look at them, people ignore them or they just blame them when it is not their fault. That is like that because, all in all, as a student said, "that is a return to childhood, but you are not a child any more so that if you don't wake up and keep the rhythm you are trampled like a rat".

To sum up, what hides behind I feel [...]? what makes students feel this way? why do they feel like that? These three questions can be answered with three ideas: people make them feel like that, the context makes them feel this way, the fact that they do not the stage makes them feel like that. The oppressor mechanism has worked, the way of calling the students and dealing with them has made it possible for them to feel they are nobody so that they are ready to get promoted inside the institution. That is the beginning of the end of the role of the first year students. The experience they have gained as well as the personal defense mechanism developed, together with the fact that next time they enter a hospital they will be students of the second year, which implies a higher status.

A dissenting role. A student with a great deal of professional experience was surpised by the way people dealt with him: he said he had just found out a new figure concerning this hierarchy, it was the lowest one and it could be compared to that of the pariah of the Hindu castes. He said it was necessary to find a new name for that concept because as fas as he was concerned there was no name to refer to that.

It was true that the student had experienced a new role, still unknown to him, he had identified something that existed before he started working in this field and that he will never forget. In sociology as well as in anthropology, similar despersonalization roles have been described in jail, psychiatric hospitals or convents, all of them in total institutions (Taylor and Bogdan, 1984; Goffman, 1961). The difference concerning our students is that those roles are determined by the fact that they are training nurses. Goffman describes a social role similar to the one described by students of nursing. He calls that dissident role and it can refer to lift attendants, servants or drivers of a car of the 60s (Goffman, 1959).

Which are the characteristics of the dissident role? According to Goffman (1959) the role of the person who plays thir role has not a fixed script to play on the stage, they go unnoticed, that is, the other actors do not take them into account, they are invisible and in this sense, they are nobody. They play a asubordinate role but hey are in a certain way like the members of the team because together with them, they can look at the scenic background and they can also know what hides behind the stage although it is clear that they cannot express themselves because of their social invisibility or just because they do not exist.

Taking into account what we have said before, it is easy to establish a relationship between nursing students and the dissident role. It has been pointed out that students go unnoticed, they are invisible and feel nobody. Students play the role of servants and do not have access to the secrets hidden behind the stage. Nevertheless, this role has two characteristic that need clarifying and those are the subordination and the lack of a fixed script. A future analysis of the journal fields will shed a new light.

At the same time, the study shows two anomalous qualities which do not coincide with the characteristic of the dissident role: I am talking about institutional mistreatment and disciplinary measures described by students and about the provisional nature of the role. Institutional mistreatment (Foucault , 1975; Berger and Luckmann, 1961) is an institutional control system included in the disciplinary sanction system, which is the group of mechanisms that institutionalize the inexperienced person and show the order of the internal logic of the institution. Those two aspects have to do with the smooth running of some institutions -prisons, psychiatric hospitals, convents-, though with the information we have after this first approach, it is not possible to make it clear.

The provisional nature of the role played by students is the consequence of the logic of the university educational system- which specifies a limited period of training- together with that of the health institution.

For example, students in May are inexperienced first year students and from June of the same year they are experienced second year students. From a lineal point of view, it is just a month that has gone by but according to the University regulation -legitimized institution-, students have to continue studying because they are still second year students so that they have to study for one more year in order to hold a diploma in nursing. The dissident role of the "first year students" is as volatile and brief as the training period at hospital, which lasts for two months. Therefore, it is a temporary dissident role, brief and reversible, although it is intensive and emotional as well.

References

     Amezcua M (2000). Enfermedad y padecimiento: significados para la práctica de los cuidados, Cultura de los Cuidados, IV(7-8), 60-67.
     Amezcua M y Gálvez A (2002). Los modos de análisis en investigación cualitativa en salud: perspectiva crítica y reflexiones en voz alta, Revista Española de Salud Pública, 76(5),423-436.
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