Pleasure and suffering in the training of doctors in nursing: a descriptive study

Maria José Quina Galdino1, Julia Trevisan Martins2

1 Universidade Estadual do Norte do Paraná

2 Universidade Estadual de Londrina

ABSTRACT

Objective: to reveal the situations of pleasure and suffering in the process of training doctors in nursing. Method: a descriptive study, with a qualitative approach, whose data were collected with 16 PhD students from Postgraduate Nursing Programs at public universities in southern Brazil. Content analysis was used to organize the data and the Psychodynamics of Work as a theoretical framework. Results: pleasure was related to scientific improvement, sandwich doctorate and interpersonal relationships, especially with the supervisor. Suffering occurred due to academic productivity, the frustrating relationship with the advisor, the overwork arising from managing doctorates, work and personal life, and the expenses related to the course. Conclusion: the process of training doctors was permeated by the contrast of pleasure and suffering.

Descriptors: Emotions; Nursing students; Graduate Nursing Education.

INTRODUCTION

The doctorate is a postgraduate course that constitutes the most important of academic degrees, whose objective is to prepare professionals for teaching and research, with a view to the continuity of scientific and technological development in all areas of knowledge. Thus, universities have increased the offer of research training positions in order to train international talent(1).

In the field of nursing, in addition to these functions, the doctorate degree has been presented as a way of consolidating the profession as a science, fundamental to the improvement of the care provided to people, since, through investigations, strong scientific evidence can be produced(2). Thus, it is believed that the Graduate Nursing Programs (PPGEnf) are increasingly committed to achieving these goals and to achieve standards of excellence equivalent to international reference programs.

 In this way, doctoral students are inserted in numerous activities with previously established deadlines and goals, among them: taking courses for credits, which provide an epistemo-methodological foundation for the development of research; being inserted in teaching activities, under the supervision of a supervisor, such as teaching classes, guiding undergraduate students and finishing work; performing a doctoral internship abroad; producing their own research, which briefly implies constructing the "state of the art" of the subject under study - providing extensive comprehensive readings of related scientific production -, data collection, elaboration of results and their interpretation, which requires aptitude with the  qualitative and/or quantitative data analysis methods; present studies at scientific events, especially international ones; and producing articles for well-qualified scientific journals with a high impact factor(3-5). In addition, the multiplicity of roles played by these students, evidenced by the maintenance of the employment relationship and the responsibilities of their private life, which can lead to physical, mental and physical wear, suffering and illness(3,5).

It is noteworthy that these simultaneous activities are configured as a “shadow” that accompanies doctoral students on a daily basis, so that they are able to carry out the activities within the established deadlines with quality and excellence(6).

 Therefore, it can be considered that the doctoral training process is surrounded by perspectives and challenges, demanding that students show resilience and determination, which can cause feelings of suffering, dissatisfaction, sadness, among others. On the other hand, this process can be permeated by feelings of pleasure, fulfillment and openness to new knowledge. However, for the experiences of pleasure to happen, doctoral students need to use individual and/or collective strategies to overcome these obstacles.

Although students are not formally considered employees, from a psychological perspective, their duties take place in an organizational structure with mandatory activities, which is similar to work(7). Thus, in this study, the assumptions of Psychodynamics of Work were used to understand the situations of pleasure and suffering that permeate the process of doctoral training, and the intellectual activity developed by doctoral students was considered synonymous with work.

According to the Psychodynamics of Work ", intellectual work can turn out to be more pathogenic than a manual work" (8:31). However, this illness is preceded by suffering, which happens when there is incompatibility between the person's expectations and the demands of the work organization, with conflicts arising regarding the purpose of the work and the significant content of the task. Not all suffering is pathogenic, as there is creative suffering, which turns into pleasure and personal development. Feelings of pleasure occur when there are spaces for individuals to develop their potential and express their subjectivity and creativity, relating strongly to appreciation and work recognition(8).

Faced with these considerations and the experiences of the authors, as a student and professor of PPGEnf, in which situations that led to dissatisfaction, wear and suffering, as well as satisfaction and pleasure for doctoral students were observed, there was the awakening for this study. The findings from this investigation may contribute to the proposition of actions that seek a teaching-learning process as pleasant as possible, and, consequently, create an environment that promotes the physical, mental and social health of these individuals.

Given the above, the research question was: What are the situations of pleasure and suffering that permeate the doctoral training process in nursing? To answer this question, the objective of this study was to unveil the situations of pleasure and suffering in the process of training doctors in nursing.

METHOD

A descriptive study, with a qualitative approach, based on the theoretical framework of Psychodynamics at Work(8). Qualitative research seeks to deepen the understanding of the phenomenon to be investigated, highlighting the subjective processes experienced by people(9).

 The investigation was performed with graduate students from two doctoral courses in nursing belonging to two public universities in the Southern Region of Brazil. The following eligibility criteria were adopted: to be a regularly enrolled student in the doctorate program in 2015, and to have completed all credits related to theoretical subjects, in order to include only students who are experiencing the activity of writing their theses.

In order to identify possible research participants, a survey was carried out with the PPGEnf Coordinations under study, which provided lists of 50 students, of whom, 24 doctoral candidates met the eligibility criteria, 12 from each university.

In order to provide similar participation opportunities to students, a manual drawing of 10 students from each of the courses was carried out with a total of 20 possible participants. However, to define the number of participants, the data convergence criterion was adopted(9), which occurred with 16 doctoral students, eight from each program.

Data collection was carried out between June and September 2015, through the self-completion of a form composed of two parts, the first referring to the sociodemographic (gender, age and marital status) and occupational characterization of the participants, and to achieve the object of the study the following guiding question was used: What situations of pleasure and suffering do you experience in your training process as a doctoral nursing student?

The information obtained in the data collection was analyzed using the thematic content analysis technique, in which we sought to identify the nuclei of meaning, that is, the presence of expressions related to the analytical object to be investigated. Thus, the data analysis process was carried out following three distinct phases: in the pre-analysis, floating reading with organization of the corpus was carried out, considering the principles of exhaustiveness, representativeness, homogeneity and adequacy, as well as how the assumptions were formulated ; in the second stage, the exploration of the material was carried out, with the purpose of reaching the core understanding of the data and classifying the categories that represent the characteristics that emerged, as well as the cuts and the choice of the recording units, with selection and coding regarding the convergence with the phenomenon; in the third and last phase, the results were treated and interpreted (9), returning to the theoretical framework of Psychodynamics at Work, in which two pre-categories were established: situations of pleasure and situations of suffering in the doctoral training process(8).

This study respected the requirements of national and international standards recommended for research involving human beings, including approval by the local Research Ethics Committee, according to Opinion No. 798.093.

RESULTS

Regarding sociodemographic data, age varied between 26 years and 61 years, with an average of 36 years. Most of the participants were female (n=12) and married (n=10). As for the occupation, five had exclusive dedication and received a scholarship, and 10 were in paid employed, six of which were nurse assistants and four were teachers.

The data analysis identified the situations of pleasure and suffering present in the doctoral training process of students, according to the thematic categories presented below:

Pleasure situations in the doctor training process

 For doctoral students, pleasurable situations were related to several aspects present in the training process.

The participants indicated that the pleasure was related to the fact that the doctorate opened up possibilities for new knowledge, deepened research, as well as being able to pass on what was learned during daily work practices, which was identified in the following extracts:

I am very happy because it has been an opportunity to learn a lot about research, to exchange experiences with other colleagues and then take what I have learned to my workplace and my personal life. (D6)

The master's degree gave me a good basis for research, but the deepening that I am experiencing in the doctorate is incomparable. My performance is another [...] currently I read a research project or see a colleague's presentation at the research seminar and I know how to identify whether the title, research question and objectives are coherent, if the justification is relevant. [...] I am better at mastering statistical programs and interpreting analyzes, [...] and have also improved my writing a lot. Without a doubt, this is what gives me the most pleasure, to see that I am progressing and maturing. (D7)

 The doctorate provides a more critical and accurate view, [...] as I read good articles on my topic, I fall in love with it more and more research ideas emerge [...] that motivates me, pushes me, I feel challenged [...]. So, this will really be my line of research after finishing my doctorate! (D12)

 Being a doctoral student in this program has several positive aspects that give me pleasure. [...] The development of professional competence in the scope of research, the friendship bonds, the fraternizations of the research groups and the study meetings that are productive and, often, challenging. (D15)

Pleasure was also related to the completion of the doctoral internship abroad, evidenced as an opportunity for professional and academic development, and international partnerships for future research, which was revealed in the statement:

 In the last year, I did a sandwich doctorate in Spain, with my husband and my son [...]. It was a unique and enriching experience, which gave me a lot of pleasure and satisfaction. [...] I was able to experience the culture of another country and the most important thing is that I improved my research knowledge. Now I feel a step ahead, with a broader view, when compared to those who have not had the same opportunity. [...] I also partnered with the doctoral students there for future research and I was invited by the tutor to be a referee for the magazine [periodical] that belongs to their school. (D11)

The participants feel satisfied due to the encouragement of the teaching staff and stressed the importance of the teacher understanding each student´s uniqueness:

 My greatest pleasure is when I realize that the teacher understands me and respects my learning time and that of my colleagues, [...] "it" flows naturally, even when there is a deadline to meet it. (D1)

 Nobody is the same and when the teacher understands it, it makes me very happy and safe [...]. There are special teachers who encourage me with difficulties, which is very important to me. (D4)

 The meetings with my advisor are very pleasant, as he transmits a lot of knowledge and conducts things with tranquility, which makes me confident. He always encourages me by saying that everything will work out and that I am capable. [...] It is such a good and respectful relationship that I can only benefit my training. When I become an advisor, I intend to have this same attitude with my students. (D7)

Suffering situations in the doctoral training process

 In this category, situations of suffering occurred in different situations during the training process. It became evident that being a doctorate student causes feelings of suffering due to the high demands related to scientific production, the result of theoretical disciplines and thesis research, as shown below:

 Virtually every discipline was evaluated according to the production of a scientific article. [...] [they] happened in a short period and there was no time to develop a consistent article. [...] the complexity in the construction of theoretical reflections and literature reviews is reduced, but to do it well it requires mastery of the method and time for analysis and writing. [...] This caused me suffering, because I had to produce something without the necessary knowledge. In the end, a good article came out and the rest of those “weak” articles, revisions with no connection, no chance of publishing. [...] This was unnecessary, exhausting and demotivating. (D5)

 I go to sleep and wake up thinking about the articles in my thesis, [...] it is a lot of pressure for me to submit and publish these articles. In fact, we are treated as like article writing “machines”. I know that this is the result of a larger system, and that is why I believe that the time allocated for completing a doctoral research with so many requirements for publication and punctuation proposed by CAPES, is insane! This pressure affects our health and our advisors health as well [...] as it is based on large research centers, such as Europeans and Americans, as if in Brazil there were the same investment and structure. [it is necessary] to review human resources on this type of researcher-teacher work. (D8)

The doctoral students indicated that the suffering also arose in view of the difficulties of the interpersonal relationship with the advisors, as shown by the expressions:

 [...] I have a lot of suffering, dissatisfaction, wear and anxiety in my relationship with my advisor. He schedules and cancels the meetings, and when it happens, I take what I managed to produce, but a loving and encouraging word is difficult. I know that sometimes it's bad, but that's what I managed to do, because I'm there to learn and there are ways to teach. [...] The relationship is a challenge; one I have not yet overcome. (D13)

 I defined what I was going to research at the end of last year, that is, after two years of doctorate [...], nothing I proposed was good [...], but all contacts were by e-mail, nothing face-to-face, I felt a little abandoned by my advisor. [...] this year out of nowhere he "resurrected" wanting everything defined, to qualify, give to the committee, collect and defend in three and a half years at most. [...] there are days when I fall into despair, I don't know if I can handle it. (D9)

The numerous activities performed by doctorates in their daily lives were mentioned as a source of suffering and physical and mental illness, as revealed in the following fragments:

 Being a doctoral student means working at home, with time to start activities, but not to finish them. [...] I always have the feeling that I do so many things, and at the same time, it seems that I do almost nothing! I cannot dedicate myself to the thesis because I am involved with so many other activities, like, corrections of abstracts for events, reports, scientific articles, data collection, organization of the research group. Another discouraging thing is not being recognized for only developing academic activities - not having a job; receive criticism for not developing professional practice directly (due to exclusive dedication). It is bad to hear comments like "do you only study?", As if doing PhD is a small thing! (D11)

Suffering?! Only those you experience it know! There are so many negative aspects, I have the responsibility to guide undergraduate students, the long weekly trips, the intense demand for activities, the pressure to publish, the competitive environment between teachers and students that generates a 'heavy' environment, among other factors that affect stress, physical and emotional exhaustion, fatigue and tachycardia. [...] Being a doctoral student is also learning daily to manage your own inner conflict, learning to measure self-collection and stress, and also allowing yourself to make mistakes, as this is also part of learning. And, in the midst of these reflections, it is clear that I already had the "not so brilliant" idea of giving up this route, but soon the will passes, or better, it has to pass. After all, being a doctoral student includes learning different lessons and also giving up the greatest value of your life: your family, because soon you will no longer be a doctoral student. (D3)

I am not managing to do all my PhD activities and I am very anxious about it; I end up taking out all my dissatisfactions and difficulties in food and I gained 18 kilos in this process. (D14)

 My data collection is affecting my sleep, there are many very complex steps. [...] lately I'm very irritated and in the last week I had a hypertensive crisis after arguing with my advisor.

For some participants, the burden is also related to the situation of doing the doctorate and doing the activities in their personal life, which generates feelings of suffering as identified below:

 I have suffered a lot due to being overloaded with activities, because I work, I have a PhD and I am still a mother, wife and housewife. (D2)

 Sometimes I feel anxious and exhausted, due to my daily routine between work and graduate school, because in the institution where I work, the employee who seeks and dedicates himself to studies and research is devalued. This is my biggest difficulty today: keep studying, as I have no break or reduction in my weekly workday. [...] I feel frustrated, because I could do much more in the academic area if I had the support of the institution where I work. If I could, I would quit my job, but I need to support myself financially. (D8)

  It was also mentioned by the doctoral students that the costs related to the doctoral course and the few resources received by the programs cause suffering, since, in addition to their personal expenses, they have to bear the expenses related to the course, as shown below:

 I have suffered a lot with the many doctorate expenses, and there is no budget for anything. I had to pay for all my collection expenses, other than what I'm spending on articles: Portuguese review, translation, submission fee and when accepted, there is a publication fee. Honestly this has led me to insomnia, because I support my home and now I am having to save a lot on the expenses of my home, and leisure doesn't even exist anymore. (D3)

DISCUSSION

 In the perspective of the psychodynamics of work, the feelings of pleasure are subjective and dependent on the culture in which the person is inserted, but generally permeates the achievement of goals, relationships and achievements. Such experiences occur when the individual is allowed a certain degree of autonomy, recognition and freedom of thought within the organization, elements that favor the development of cognitive ties with occupational activity(8,10).

The pleasurable situations experienced by doctoral students in their training process were related to the improvement of knowledge, skills and abilities in the professional and academic spheres. In this sense, the doctorate aims to enable graduate students to become independent researchers, in order to contribute to the generation of knowledge and improvement of practice through research(1,4). However, it is expected that these students present different levels of writing skills and mastery of technological tools to support research, which can be improved during the training period(4,11).

The feeling of pleasure perceived by the participants was also linked to the various relationships provided by the academic environment, among them the friendly and cooperative ties established with peers, who are experiencing similar situations and help each other to face individual and collective difficulties(12). Dejours postulates that in work practice, cooperation and solidarity, carry the figure of the other person beyond the simple coexistence, involving caring, interacting, confronting, learning and serving, allowing the feelings of pleasure to arise and make the environment more human and productive(8,10).

The doctoral internship abroad was evidenced as a source of pleasure as it gave the doctoral student the experience of another academic work process. The sandwich doctorate is encouraged and promoted by the Coordination for the Improvement of Higher Education Personnel (CAPES), standing out as an action for the internationalization of PPGEnf, which provides visibility to national programs and enables partnerships with researchers from other countries(2). Although this experience presents challenges such as fluency in the language, extra costs, adaptation to another culture and the bureaucracy of the process, in this study it was only mentioned as a source of pleasure and professional and personal development.

Pleasure was also seen in the mentor-mentoree relationship, especially when the teaching-learning dialogue prevails in the orientations, in which the teacher plays the role of the guide and mediator of knowledge, encouraging the graduate students to explore their potential, and helping them with their difficulties. Furthermore, the mentor's perception of the student's personality, active listening and empathy became relevant, as each individual is unique and needs time to assimilate and perform tasks of which he/she does not have mastery, supported by the assertion that the learning process is not watertight.

Similarly, the relationship becomes rewarding when the advisors are accessible and demonstrate understanding regarding the challenging and unique circumstances experienced by the students, and when the graduate student experiences periods of stagnation in his research, the welcoming and encouraging attitudes of the advisor they are essential for academic progress, and prevent the study from being distanced and seen as a source of suffering(13).

It is worth emphasizing that this pleasant relationship will certainly contribute to research causing it to be developed with more enthusiasm and dedication, resulting in the student becoming an effective researcher with a defined line of research after the doctorate.

 However, as in any interpersonal relationship, there may be divergent thoughts and opinions and, consequently, disagreements are likely to happen which cause suffering in the student and the advisor. These conflicts can occur due to a dissonance between the expectations of both, in which the advisors expect the doctoral students to be self-sufficient and in view of their teaching overload, due to having numerous activities and students, they end up establishing an indifferent relationship, without the support and the feedback that students expect, leading to feelings of frustration. The verticalized power relations between the supervisor and student also deserve to be highlighted when they generate excessive hierarchical control and culminate in episodes of moral harassment, with conflicts related to the significant content of the task and when feelings of suffering emerging (10,14-15).

Experiences of suffering happen due to a mismatch, i.e., from the encounter of a person who has a singular and individual trajectory with a rigid, inflexible work organization which often limits the person's subjectivity and prescribes a specific operating mode(8).

Thus, situations that lead to stress and suffering for graduate students should be avoided as much as possible, as discontent and discouragement can lead to evasion or interruption of their academic career. Furthermore, it is necessary to transcend the myth that learning only happens when the training process is surrounded by a journey of great suffering(6).

 Academic productivism was mentioned as a source of suffering for students, which also affects PPGEnf advisors and coordinators. In the last decades, at a global level, researchers have experienced the “publish or perish” dilemma, which is characterized by a productivist model strongly influenced by the capitalist production paradigm, in which the individual is seen as a mere worker(5,16). For Dejours(17:34) these principles of work organization confer positive and negative consequences: “on the one hand, the extraordinary growth in productivity [...], on the other, the erosion of the place agreed to subjectivity and life at work. This results in an aggravation of mental pathologies resulting from growing work across the Western world, the emergence of new pathologies [...], the aggravation of pathologies of overload and the explosion of pathologies of harassment”.

In this context, performance based on productivity at the neoliberal university is seen as an anti-intellectual trend, with potential to harm the health of those involved and the quality of teaching, as it encourages academics to teach more students, obtain more financial support and publish more articles(6.18).

 Concerning the impact of productivism on the quality of scientific production, harmful consequences are highlighted, such as: articles with poor and little innovative methods; the practice of "salami science", that is, the fragmentation of a single discovery to publish the largest possible number of scientific articles; encouraging self-citation and self-plagiarism; the precariousness of work in graduate school and the values of the next generation of teacher-researchers, as many teachers pressured to produce outsource the task to their students, and as reported in this study, the student without the necessary knowledge is impelled to write articles(18-20).

Such premises added to those numerous activities that the participants of this study reported as part of their daily lives indicate an intense and accelerated rhythm, in which there may be an inadequacy between the present (or actual) work process and the organization of the ideal (or prescribed) work, generating overload and increasing the experiences of suffering(8,10).

Overload and an intense work rhythm lead to the accumulation of mentalenergy, which produces physical and mental wear, and in turn, trigger the process of somatization and mental and behavioral illness(10).

 However, the strenuous pace of life and overload cannot be limited to the training process, but one should consider the multiple roles of the doctoral student, who allude to the experience of a triple journey represented by study, work and personal life (family), as there is no way to separate the spheres "inside the university" and "outside the university", because the psyche cannot be divided(17).

 As many doctoral students are part-time students, the combination of the study with their other responsibilities must be carefully planned, so that their life is not reduced to the doctorate and work, and can include leisure and rest, essential to well-being and quality of life(20).

The concern with the financial costs spent on the doctorate is among the main stress-inducing situations among graduate students, which occurs both due to the scarcity of scholarships and their low values, as well as the insufficient financial resources made available for research by development agencies, in which the dispute is fierce, leading the researcher, many times, to assume all costs(6,13).

It is emphasized that occupational activities are never neutral in the context of the individual's health, the dynamic link of feelings of pleasure and suffering can be balanced or result in destabilization, fragility and cause physical, mental and social illness(8). Thus, in order to become a source of health, people must be recognized, with the purpose of giving meaning to the suffering experienced, transforming it into pleasure, personal development, construction of their own identity and self-realization.

CONCLUSION

The process of training doctors was permeated by situations that led to feelings of pleasure, related to the possibility of personal, academic and professional growth, through the acquisition of new knowledge and the interpersonal relationships established during the training. However, this process also caused feelings of suffering in the doctoral students, which are related to the high demands for scientific production, difficult relationship with supervisors, the multiple roles played by the student and the financial costs related to the doctorate.

Although the objective of this research has been achieved, it is necessary to consider the results in their individuality, as it was only performed in two doctoral courses and investigating feelings involves the uniqueness and subjectivity of the participants.

Further investigations must be carried out with the teachers of these programs, as they may be experiencing situations of pleasure and suffering in their work process that may influence their living and health conditions.

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Received: 09/25/2016

Revised: 11/22/2019

Approved: 11/22/2019