Education is important in shaping professional identity, including how one approaches norms and normalisation. In the analysis presented in this study, nursing students' own constructions of norms and normality from the outlook of their education are highlighted and problematised. To deepen the understanding of these matters, the aim of this study was to explore constructions of norms and normality among students in nursing education. Students studying in a nursing department at a Swedish university college were approached and asked to consider open survey questions targeting their views on norms and normality; 154 of them replied. After a discourse analytic approach to the data, we could see how the students constructed norms and normality as (a) instrumental instructions, consisting of easy‐to‐digest statements grounded in the profession's obvious moral and ethical values, (b) limiting and frustrating obstacles for personal freedom that were important to challenge, (c) rules to be obeyed for the stability of society and (d) a matter of reflection, with each individual being responsible for understanding differences in norms, perspectives and opinions. We conclude that nursing education would benefit from norm‐critical perspectives, problematising students' own positions to norms, power and privilege.

Background

This dissertation takes a critical look at norms and normality in healthcare education, focusing on the specific case of a nursing education programme at a Swedish university college. The concepts of norms and normality have a long history in healthcare professions, and have become important for many aspects of social life. A norm-critical perspective is central to the studies, as it exposes constructions of power and privilege related to norms and normality. It may also be useful in revealing underlying assumptions and matters which healthcare professionals take for granted, and which may result in failure to provide equitable care for all.

Aim

The overall aim of the dissertation is to describe and scrutinise norms and normality in a healthcare education context from a norm-critical perspective. A further aim is to explore how a norm-critical perspective on nursing education can contribute knowledge to existing fields of critical inquiry.

Designs

The four studies were designed using qualitative approaches to written and spoken text, as well as a number of different approaches to an instrument development process.

Methods

In study I, document analysis was underpinned by thematic analysis, while critical discourse analysis was used to analyse focus group discussions in study II. Study III analysed written responses to open survey questions using a discursive approach. Instrument development and factor analytic techniques were used in study IV.

Findings

Study I revealed the occasional use of politically correct rhetoric in curricular documents and literature, in parallel with a number of outdated views in terms of identity and normality. In study II, three discourses were identified in nursing teachers’ talk, all with norm-critical potential, though criticism of norms was not strong enough to form a discourse of its own. Study III showed how nursing students used more or less politically correct or reflexive approaches to construct images of norms and normality. Study IV developed and validated the Norm-critical awareness scale.

Conclusions

This dissertation expands knowledge about norm-critical perspectives in healthcare contexts. It exposes constructions of normative, taken-for-granted aspects within healthcare education, and concludes that the apparently desirable concept of tolerance needs to be problematised more fully in relation to norms, privilege and power. Norm criticism as an educational and intellectual tool can increase awareness of the norm-related mechanisms underlying healthcare encounters, even if awareness is only a first and necessary phase of change, and is not in itself sufficient to bring about change.

Implications

In a practical sense, the findings can facilitate understanding, planning and implementation of further norm-critical initiatives in educational contexts. Where theory is concerned, the studies fill a knowledge gap by contributing to norm-critical approaches in settings where future healthcare professionals are being educated, which have barely been explored until now. The studies also add to existing research traditions involving critical, emancipatory and anti-oppressive perspectives in terms of healthcare professions.

Purpose

Healthcare professionals' conscious or unconscious norms, values and attitudes have been identified as partial explanations of healthcare inequity. Norm criticism is an approach that questions what is generally accepted as "normal" in society, and it enables professionals to identify norms that might cause prejudice, discrimination and marginalisation. In order to assess norm-critical awareness, a measurement scale is needed. The purpose of this paper is to develop a scale for measuring norm-critical awareness.

Design/methodology/approach

The scale-development process comprised a qualitative item-generating phase and a statistical reduction phase. The item pool was generated from key literature on norm criticism and was revised according to an expert panel, pilot studies and one "think aloud" session. To investigate the dimensionality and to reduce the number of items of the scale, confirmatory factor analysis was performed.

Findings

The item-generation phase resulted in a 46-item scale comprising five theoretically derived dimensions revolving around function, consequences, identity, resistance and learning related to norms. The item-reduction phase resulted in an instrument consisting of five dimensions and 20 items. The analyses indicated that a summary score on the scale could be used to reflect the broad dimension of norm-critical awareness.

Originality/value

The Norm-critical awareness scale comprises five theoretically derived dimensions and can be used as a summary score to indicate the level of norm-critical awareness in educational contexts. This knowledge is valuable for identifying areas in greater need of attention.

The documents and literature that regulate nursing education are based on certain values and knowledge, and the underlying power in the curriculum raises the question of how health care professionals are molded during the course of their education. Norm criticism is a concept with its roots in critical pedagogy and gender and queer studies, emphasizing the origins as well as the consequences of marginalization, power, and knowledge of what is generally accepted as "normal" and "true." Norm criticism is used in this article to analyze the documents and literature underlying a nursing program in Sweden, which are shown to include a sometimes politically correct rhetoric, but one lacking a firm basis in social justice values.

This paper describes the discourses underlying nursing teachers’ talk about their own norm-critical competence. Norm criticism is an approach that promotes awareness and criticism of the norms and power structures that exert an excluding effect in society in general and in the healthcare encounter in particular. Given the unequal relationships that can exist in healthcare, for example relationships shaped by racism, sexism and classism, a norm-critical approach to nursing education would help illuminate these matters. The studied empirical material consisted of focus group interviews. Nursing teachers discussed their norm-critical competence based on the university course “Norm-Aware Caring” in which they had recently participated. Through a critical discourse analysis, three discourses were identified in their talk, all of which had the potential to disrupt traditional, normative nursing education. However, in all three discourses there was an underlying discourse of normality, clearly positioning the teachers as exemplifying the “normal.” The binary constructed between normality and otherness contradicts a basic tenet of the norm-critical approach and may hamper the development of genuine norm-critical competence in nursing education.

Bakgrund. Normkritisk kompetens är en förutsättning för att kunna ifrågasätta rådande, begränsande normer som skapar ojämlikhet. Att kunna mäta normkritisk medvetenhet är nödvändigt av flera skäl, exempelvis för att kunna identifiera kunskapsbehov eller utvärdera insatser. Idag finns dock inget vetenskapligt baserat instrument för detta ändamål.

Syfte. Studien syftar till att utveckla ett instrument som kan mäta graden av normkritisk medvetenhet.

Metod. Utvecklingen av instrumentet omfattade två faser: (1) generering och test av items samt (2) reducering av items genom konfirmatorisk faktoranalys. I den första fasen formulerades och testades validiteten i items genom expertbedömningar, pilotstudier och samtal med studenter, vilket resulterade i 46 items. I nästa fas analyserades dessa med konfirmatorisk faktoranalys i syfte att reducera instrumentet till 20-25 items för att få ett mer lätthanterligt instrument.

Resultat. Faktoranalysen resulterade i 20 items och fyra dimensioner. Dimensionerna var Normers konsekvenser, Att lära sig normer, Motstånd mot normer och Normers funktion. Det visade sig också att de fyra dimensionerna tillsammans mäter en bred dimension (normkritisk medvetenhet).

Diskussion. Utvecklingsprocessen reser frågor kring styrkor och svagheter med att operationalisera och kvantifiera kvalitativa fenomen så som medvetenhet om normkritik. Det utvecklade instrumentet kan användas för att mäta normkritisk medvetenhet i olika sammanhang, exempelvis effekten av normkritiska utbildningssatsningar inom högre utbildning.  

Background: Nursing education in Sweden generally lacks norm-critical perspectives, even though this could help unveil normative judgements of patients in nurses’ daily work. To pursue work-integrated learning about norm criticism for nursing teachers at a small university college in Sweden, all teachers involved in nursing education were offered the course Norm-Aware Caring.

Aim: To describe how norm criticism in nursing education is constructed by nursing teachers’ discussions.

Methods: After the course Norm-Aware Caring, 20 of the participating 33 nursing teachers were interviewed in five focus groups about their reflections ontheir new knowledge. The interview transcripts were analyzed on the basis of Fairclough’s discourse analysis, in which words and social practice are seen as mutually constituting each other.

Results: Discursive constructions related to teaching, caring and learning were seen in the text. Norm critical teachingwas constructed as a practice of much consideration not to insult any student. Norm criticism as abasic caring valuewas closely related to person-centered care. Their own, personal learningwas expressed as fear to use their new knowledge in a wrong way. The teachers themselves considered norm-criticism as something to learn in order to improve the understanding of people who does not fit into majority norms. This perspective of tolerance was consistent in the construction of all discourses.

Discussion: It appears that the teachers’ social practice is influenced by a perspective that divides the “normal” from the “deviant”. This may prevent an internalization of norm-critical knowledge, a perspective that aims to question categorizationsofnormality. Therefore, it is important to continuously scrutinize and reflect over the role of social norms as part of work-integrated learning for nursing teachers.