K Zagenhagen, G van Rensburg
Background: Students and nurse educators in a military teaching and learning environment experience role con ict as a result of being simultaneously a professional nurse and a soldier.
Purpose: The purpose of this article is to highlight the professional ambiguities experienced by students and nurse educators as a result of their dual roles as nurse and soldier within a military teaching and learning environment.
Methodology: A qualitative, grounded theory method was used. Data was collected by means of focus groups and critical incident narratives. The transcribed data was analysed using Charmaz’s constructivist approach.
Results: Four themes emerged from the data, of which the most significant was the aspect of professional role conflict. Nurse educators and students experienced professional role conflict in terms of dual roles, military requirements, professional conduct, command and control, professional roles, humaneness, professional ranks, assertiveness, leadership styles, authority and ethical principles.
Conclusion: Neither nurse educators, nor students seem to be sufficiently prepared to deal with fulfilling dual roles as nurses and soldiers as it mostly causes conflict and confusion.
Keywords: nursing professionalism, military professionalism, dual roles, military teaching and learning environment, nursing education
Conflict of Interest: The first author received funding from the University of South Africa, Sigma Theta Tau International and the Safety and Security Sector Education and Training Authority to complete the study.
The South African Military Health Service (SAMHS) Nursing College is responsible for the training of military nurses to meet the healthcare needs of the South African National Defence Force (SANDF). As such, the College is currently offering a 4-year programme leading to registration as a nurse (general, community, psychiatry) and midwife at the South African Nursing Council (SANC).
Students who are recruited and selected to follow this programme commence their careers with basic military training, followed by an officer’s formative course aimed at equipping them with the necessary skills, knowledge and values to function as junior military officers in a specific, designated military environment. Afterwards, these students start with nursing training at the SAMHS Nursing College.
The SAMHS Nursing College is situated within a military environment. Students as well as nurse educators are therefore exposed to a unique teaching and learning environment inundated with military culture. The complexity of this environment led the researcher to investigate possible factors implicit to the military organisational structure, culture and learning environment, that may have an influence on the professional socialisation of student nurses. The focus of this article will be on the most controversial of these factors, especially the aspect of professional role conflict.
A qualitative, constructivist grounded theory method was used to explore the nature of the hidden curriculum in a military teaching and learning environment, and to determine its influence on students’ professional socialisation.
The accessible population consisted of nurse educators and students of the SAMHS Nursing College. A non-probability sampling approach was employed to select the study participants. The nurse educators were selected by means of purposive sampling and were eligible to participate if they were a registered nurse with at least three years’ experience as educator at the College. Ultimately 15 of the 23 nurse educators who met the criteria and consented to participate, were invited. The students were eligible to participate if they were registered for the four-year Diploma in Nursing (General, Community and Psychiatry) and Midwifery and were in the fourth year of training. Through convenience sampling the entire group of 56 students were invited and of which 12 students consented to participate.
Data was collected by means of focus-group interviews and critical-incident narratives. Two focus-group interviews were conducted with the nurse educators and students respectively. In addition the students were requested to write critical-incident narratives.
Each focus-group interview was audio-recorded and transcribed. The critical-incident narratives were thematically analysed. Thereafter Charmaz’s constructivist approach1 to data analysis was applied. This approach entailed a continuous loop of open coding, focussed coding, theoretical sorting, diagramming, theoretical integration and theoretical coding. Theoretical sensitivity, intuiting, memoing, re flexivity, constant comparison and theoretical sampling were further applied to ensure data quality. Ultimately, the data from all four focus groups and the critical-incident narratives were integrated to form one data set. A detailed description of the data collection and analysis is available in the original study2.
The researcher obtained ethical clearance from the academic institution where the study was conducted and the Military Hospital Research Ethics Committee. Permission to conduct the study was obtained from the Nursing College and Defence Intelligence. This also ensured institutional protection. The ethical principles of beneficence, respect for human dignity, justice and respect for the scientific community as expressed in the Belmont Report3 were applied throughout the study.
Each participant was provided with an information letter which informed them of the full nature of the study, what would be expected of them and their rights. In the absence of any objections, an informed consent form was signed.
Four themes were derived from the integrated data. Each theme was metaphorically labelled to resonate with the experiences related by the nurse educators and students.
• Theme 1: You’re in the army now! – military acculturation
This theme relates to the categories that emerged from the data which encompassed aspects associated to the participants’ transition from civilians to soldiers.
• Theme 2: Off to boot camp – professional knowledge acquisition
Theme 2 relates to the processes taking place in the theoretical learning environment whereby students are taught the knowledge and skills necessary to execute their roles as nurses.
• Theme 3: Off to the battle eld – clinical skills acquisition
This theme represents the clinical learning environment where students are sent to apply the knowledge and skills they acquired in the theoretical learning environment.
• Theme 4: Fighting a dichotomy – professional role conflict
Theme 4 addresses the strong contrast between simultaneously being a professional soldier and a professional nurse.
As indicated earlier, the most controversial finding was the aspect of professional role conflict. The findings presented hereafter represent the categories and sub-categories which lead to the formation of Theme 4. It is significant to note that most issues related to professional role-conflict were raised by the nurse educators, although some students did acknowledge the existence of dual roles and how it affected them. The findings are substantiated by verbatim extracts from the data. Some verbatim extracts were modi ed for clarity purposes.
•Command and control
Military command vs functional control: The military hierarchical ranking system results in military rank taking precedence over professional rank, professional experience, professional qualifications and academic qualifications. A commander is assigned military command by virtue of rank and appointment, while a healthcare professional in control of a professional grouping is assigned functional control.
There are times when you are led by somebody who does not have insight into the nursing education. He doesn’t have that knowledge that you are expected to do this many hours. You are expected to do this. But my problem is the interference of military into the professional development of the student where we are treated as equal irrespective of the expectations of the courses that we are doing.
- LeadershipAutocratic leadership style vs democratic leadership style: Participants agreed that whereas the Defence Force is generally seen as an autocratic organisation, the nursing profession is seen as being more democratic.Then there are times where it becomes difficult for nurses because with the Defence Force we must deal with, I can say; autocrats. In the nursing profession, they are taught that you can’t manage without the input of other people.So there are periods of contradiction when you compare the military and the civilian people.
Fearing authority vs respecting authority: It was said that, in the Defence Force authority tends to instil fear rather than respect.I remember when you were a professional nurse at the civilian hospital, you will be in the ward controlling everything, doing something. But, you know you have got this Matron who will come for rounds. But when he comes, you stand up showing respect, but not fear.So, what is happening is, in a way, a rank instilling fear in individuals. It is worse if you … you were not socialised in the military.
- Professional ranksMilitary rank vs professional rank: Military nurses are given both a military rank and a professional rank, but the military hierarchical ranking system results in military rank taking precedence over professional rank. The military rank does not always re ect the professional level nor does the professional rank always re ect the military seniority.I would say a visitor visiting the patient, they know these ranks. They will go to the one-pip Lieutenant who doesn’t know anything and say but you now help me with this and this and this and overlook the others who are actually more senior, but ignored because of the rank. So the rank actually disadvantages the profession. In terms of the military, the rank is given higher attention than the professionals, the professionally itself.
Being submissive vs being assertive: A lack of assertiveness, a sense of responsibility, inquisitiveness and self-confidence amongst students are ascribed to the nature of the military culture and the enforcement of discipline and obedience, which leads to what is perceived as respect and submissiveness. Assertiveness is an essential skill in order for nurses to be advocates for their patients. Being a disciplined, obedient soldier, however, requires nurse educators and students to be submissive rather than assertive.
The one thing that I have observed, when you are coming from the civilian world, compared to the military environment, what I have seen with the military students, they are more … respectful or submissive. For I have seen submissiveness, which is regarded as discipline in the military. For me it is not okay.
• Professional roles
Disciplinarian vs carer: The military and the nursing professions are both seen as disciplined professions, but the need to discipline a student at the one moment, and then to act as a caring role model the next appeared to be very difficult for nurse educators.
Then, now you are calling the student … because they have done something wrong… Now, on the other side, now that caring personality comes up … So the roles now … the student is confused. You have just finished disciplining the student in that soldiering manner to say this will not be allowed …The next second you have changed completely.
Disciplinarian vs educator: Conflict between being a disciplinarian but also an educator were raised. They regarded nursing education as their core function and found it difficult to discipline students in a military fashion at the same time.
The difference would be the core, the core function. Me, I came here as a nurse educator. That is my core function. I have to develop this student as a professional nurse. But because I am in the military set-up, I have to know what military status entails, what I must do.
Emotionally undemonstrative vs empathetic: Being emotionally undemonstrative as a soldier but empathetic as a nurse also posed a challenge to the nurse educators.
Then I will push students to come back to the hospital and how there they are a soldier and they had to do the military things and have to be this strong and an assertive type of person. But now, they come back and you have to be this caring type of person. I think it is very confusing sometimes.
Being treated as an object vs being treated as a human being: Military indoctrination deprives one of one’s humanity and leads to depersonalisation, de-humanisation and de- emotionalisation. This results in the tendency to overlook the individual person behind the uniform and rank. Students regarded themselves as being treated like objects in the military environment as opposed to being treated like human beings in the civilian environment.
Our students now, with this culture and the civilian culture, because you are placing them here in the military environment and also outside, they would say outside, there in the civilian world they are treating us like human beings. But here at xxxx, they are treating us like objects.
• Ethical principles
Being a soldier first vs being a nurse first: The participants felt especially strongly about non- nursing duties taking precedence over nursing training. They claimed that military expectations often outweigh professional expectations.
… to a certain point, you have to stand up for your patient care, because that is, at the end of the day, your profession. That is what you want to do. Because your patient comes first, irrespective whether the military tells us that rank comes first or a soldier comes first, because that is what they tell us. They tell us you are a soldier first and then your profession… But if we don’t teach them assertiveness, if we don’t teach them that, you know, you have to be the advocate for your patient.
Inflicting harm vs beneflcence and non- maleflcence: The principles of beneflcence and non-maleflcence as taught to students during nursing training stood in strong opposition to what they are taught during Basic Military Training in terms of musketry and warfare.
Then there is also the aspect of, I don’t know [whether] it relates, but, do no harm. Beneflcence, non-maleflcence. You are taught to shoot here. You go to the shooting range and you are given a weapon. We have been there, we have done it. Now you come here and you have to care and you have to treat.
The rights of soldiers vs the rights of nurses and patients: The rights of soldiers – or rather their lack of such rights – was contrasted with the rights of nurses and patients.
They say … you don’t have the right as a soldier. This is our culture you know, our rights are taken off. But in a nursing profession, we teach students the patients’ rights and the nurses’ rights.
Military instructions vs patients’ rights: Ethical conflicts were often experienced when students were confronted with a military order or instruction from a higher-ranking officer, especially when in contravention of the patient’s right to privacy and confidentially.
The issue of ranks also come into play when you are taught to respect a higher-ranking [officer]. When higher-ranking officers come into the ward, you have been taught to respect this person.So, here comes this General, he is asking me as a CO about the Private’s condition in the ward. We have spoken about the patient’s right. Do I respect the patient’s right to privacy and confidentiality or do I respect the higher-ranking officer who is asking me to divulge the person’s private information and give [the information]?
Patient’s rank vs patient’s needs: The ability to oversee patients’ ranks and treat them according to their health needs was regarded as a challenge by students.
I feel that in the military, as a nursing student or as a nurse … how it has affected my profession is that you have to be a soldier and a nurse at the same time…You find people of higher ranks. There you have to consider their rank before you can treat them.
The military setting presents one of the most complex dual relationship situations for health professionals. These complexities are derived from the fact that military health care professionals always act the dual roles of carer and commissioned military officer4.
Most of the topics around moral dilemmas and role conflict related to dual loyalties in the Defence Force that have been discussed in the literature5,6,7 have been described against the backdrop of wars, violent conflict and operational deployment. After all, that is what soldiers, and by extension, military nursing students, are trained to cope with.
The types of military operations and the setting of the military operational theatre worldwide have changed over the last few decades. This has subsequently brought about a change in both the identity of the military officer and in the primary roles of military healthcare professionals8. The changes in the primary roles of military healthcare professionals may explain why the professional contradictions experienced by nurse educators and students in this study do not refer to the moral and ethical dilemmas that one would expect to encounter in a combat zone, but to day-to-day issues during times of peace2.
The highly contrasting roles of nurse and soldier allow nurses to cross these boundaries with relative ease, each being clearly de ned in terms of responsibility and authority. External pressures – such as a direct threat – are fundamental to the transformation from nurse to soldier: The highly contrasting roles of nurse and soldier allow for a degree of compartmentalisation of identities or mental fences that separates each role to be negotiated and overcome4. The current absence of direct threats in the working lives of nurse educators and students at the South African Military Health Service Nursing College may explain why they find it difficult to assume both roles or to switch between the roles.
In another study, also conducted on a military teaching and learning environment, Caka, Van Rooyen and Jordan9 highlight the dual transition of student nurse to professional nurse and from candidate officer to officer. These students, when qualified, were neither regarded as competent professional nurses nor competent soldiers. This could be ascribed to the challenging transition period where students are expected to fulfil military as well as nursing demands. In the same study, students gave an indication that they are not being adequately prepared for the dual roles throughout their training.
Caka and Lekalakala10 found similar experiences amongst military nursing students who indicated that they feel confused where they were expected to undertake dual roles, especially conflicting ones. The same applies to the participants of this study, as they became confused most of the time between the two contrasting professions and not knowing to which they belonged.
This study revealed that military nurse educators and students need to be multi-skilled to respond to the dynamic and complex military teaching and learning environment and be adaptable and flexible to be able to reconcile the conflicting identities of nurse and soldier. The ability to adapt and adjust to changing circumstances is after all what makes military nurses unique and distinctive.
A situation where there is more than one obligatory course of action, constitutes a moral dilemma and prolonged exposure to moral dilemmas may lead to moral distress11. It could therefore be deduced that the conflict of duty experienced by nurse educators and students as reflected in this article and the subsequent inability to resolve conflicting moral judgments may result in moral distress.
In order to assist nurse educators and students to effectively reconcile the two roles of nurse and soldier, it is recommended that proper socialisation and identification with the professional standing of military nursing be improved through strengthened education, training, and development opportunities for military nurses.
Corresponding author: Gisela van Rensburg [email protected]
Authors: G van Rensburg1, K Zagenhagen2
1 University of South Africa
2 South African Military Health Service