A Critical Discourse Analysis of Undergraduate Nursing Students’ Experiences of Learning Dignity-enhancing Care within the Clinical Learning Environment

Student thesis: Doctoral ThesisDoctor of Education


The nursing profession has been challenged to improve standards of care in the UK. Nursing has been, and continues to be, considered a caring profession, but this reputation has been undermined since the events in Mid-Staffordshire Hospitals emerged between 2005 and 2009. The ensuing debate in the professional nursing journals sought to apportion blame under the guise of seeking solutions. Many arguments were revisited. This included scrutiny of undergraduate nursing education post-1996 when provision moved predominantly to the higher education sector. The aim of this body of work was a positive orientation question, seeking to find solutions to the question ‘How should we educate undergraduate nursing students to deliver dignity in care’?

A critical review of the literature was performed. Undergraduate nursing students were a limited presence, suggesting gaps in that literature. Four themes identified were used to generate a research question and ongoing critical examination of the topic: the significance of dignity-enhancing care for patients built upon an ethic of care (Gastmans, 2012); the learning journey undertaken by undergraduate nursing students as they engage with situated practice; the importance of the pedagogical moment to their learning (van Manen, 1991); the role of moral agency in supporting undergraduate nursing students to enact their ethic of care. Discourse analysis was identified within that literature as a suitable methodology to explore the identified themes with the undergraduate nursing students.

Research Aim
1.To uncover characteristics of the pedagogical moment in undergraduate nursing students’ clinical practice placement journey as they learn dignity-enhancing care;
2.To make recommendations for undergraduate nursing curricula.

Research Question
How do undergraduate nursing students linguistically represent dignity in care as a pedagogical moment in clinical practice placements?
I. What are the characteristics of appreciative examples?
II. What are the characteristics of negative examples?

Methodology and Method
Critical discourse analysis was undertaken using an adaptation of van Leeuwen’s analytical approach (2008). By exploring the undergraduate nursing students accounts of pedagogical moments within their clinical practice placement journey, their linguistic representations of dignity in care were used to uncover learning. An iterative research process first sought permission to access students reflective writing (Phase one, 87 reflective accounts were retrieved from 63 students) and this was used to develop an interview schedule; Phase two involved semi-structured interviews with a purposive sample of undergraduate nursing students (N=6, with 2 from each year of programme); Phase three involved selecting paradigm, fringe and deviant cases for critical interrogation using van Leeuwens’ framework. Five patterns in the data were extrapolated and used to build claims as the basis for conclusion and recommendation (Wood and Kroger, 2000).
The adaptation of this analytical framework required considerable iterative, critical development to assure rigour and methodological integrity. A reproducible procedure was developed to assure trustworthiness. Van Leeuwen’s (2008) framework has (to the author’s knowledge) not been applied in this healthcare setting previously and considerable work was needed to relate it as faithfully as possible to this subject and setting. It has provided an iterative, rigorous process to assure trustworthy findings and therefore a most useful lens with which to explore the data.

Five patterns were developed, arising from this analysis as composites of the participant interviews. These were a challenging learning environment, ethical and moral dilemmas, moments in care, navigating clinical cultures, and personal and professional growth.

Various modes of construction were evident in challenging learning environments. Participants spoke of distress and vulnerability, shame and embarrassment, all of which signals compromised learning opportunities. Participants rely upon personal authority to enable agency, and this develops their ability to show initiative. The implications of the losses associated with this compromised learning, impact upon not only the student but also the patient, the organisation and the profession.

Ethical and moral dilemmas were evident. The patients are central to participants’ consideration and considerable attention is paid to learning to advocate for them. The participants construct such advocacy as speaking up for patients and this is a longitudinal, developmental aspect of the data. Speaking up for their own learning is practised less often and participants are vulnerable in the clinical practice placements. Moral courage is the predominant moral concept observed in the data. Non-trained staff exert great influence upon students learning to assimilate ethical and moral dilemmas. No ethical framework was identified in the students’ narratives. The focus in this thesis shifted from patients’ experience of dignity in care to undergraduate nursing student-oriented dignity as a vital precursor of dignity-enhancing care.

Participants themselves were able to appreciate significant pedagogical moments. This was evident in action but also after the event when prompted through reflection as a written exercise and during interview. Dignity in care is held by both staff and patients in the practice setting. Participants were able to use negative experiences to establish positive learning. The personal and the professional were seen to be acting in tandem in this pattern.

Navigating the clinical practice placement cultures involves developing adjustment and coping mechanisms, adaptability, and learning that ‘nurses eat their young’. Participants are particularly vulnerable to clinical team dynamics and organisational cultures. Overall, the learning uncovered in this study is dynamic and relational, but frequently personal worth as an undergraduate nursing student is challenged and deeply reflected upon. They will create their learning from the placement journey and identity work will come from deriving meaning through experience.

The five patterns were discussed within the context of the wider literature and four claims are presented to capture the enduring themes emerging from critical review of the literature, analysis and discussion. Firstly, Dignity-enhancing learning is suggested as the basis for delivery of dignity-enhancing care by undergraduate nursing students; Challenging learning environments and unhelpful cultures are rendering undergraduate nursing students more vulnerable. When related to existing empirical studies, this indicates the risk that dignity in care may not be practised. Curricula and culture were identified as key elements of the findings, indications are that they need to be learner-centred, foster personal resilience and value agency. Secondly, facilitation of students’ personal and professional growth is indicated to be a pivotal, longitudinal aspect of undergraduate nursing curricula. Thirdly, moral courage is an attribute that should be fostered. Whether it is enacted to advocate for patients or extended to include indirect patient care issues such as poor practice learning opportunities, it can be supported as a positive learning opportunity. Moral courage to promote dignity in care should be taught and facilitated, role modelled, and captured for undergraduate nursing programmes. These findings are applied to propose an extension to Corley’s (2002) Moral Distress theory. Fourthly, self-agency can be supported and developed within curricula to enable students’ well-being.

Positive conclusions have arisen from this body of work. There is an empirical evidence base regarding how dignity-enhancing care can be taught and learned. The participants in the study were learning to practice dignity in care, which can be understood when viewed through a framework of an ethic of care and moral agency. Moral courage was practised by the participants in response to concerns about standards of patient care. The participants encountered challenging learning experiences and where these were related to patient care, they used them to increase their determination to deliver good nursing care.

Negative findings were also uncovered and these offer potential for curriculum. Key concepts were found to be absent in the data, such as the lack of ethical frameworks to support clinical decision-making, and the limited use of moral courage regarding their learning experiences. Mentorship and the use of reflection were positive when utilised, but their presence in the data was limited. Professional identity formation was also an unstable aspect of the students’ experiences and worthy of further study.

This thesis makes a unique contribution to knowledge in a number of ways: Gastmans’ (2013) Dignity-enhancing care model and a formative curriculum model of dignity-enhancing learning is proposed for further exploration; Short-, medium, and long-term implementation goals are proposed; incivility has been linked to dignity-enhancing care as an outcome using empirical investigation; personal, professional and organisational goals are dependent upon the extension of moral courage to poor learning environments and a pathway has been developed based upon the findings; Van Leeuwen’s analytical framework for critical discourse analysis was adapted and used in a new discipline, providing the methodological lens of social cognition to nursing practice.
Date of Award2022
Original languageEnglish
SupervisorMurray Simpson (Supervisor), Stella Howden (Supervisor) & Alison O'Donnell (Supervisor)


  • Critical Discourse Analysis
  • Dignity
  • Undergraduate nursing students

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