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Nursing students' perceptions of their chosen profession.

ABSTRACT It has been suggested that students enter nursing programs with strong images of the profession and specific expectations of their educational experiences. However, little is known about the impact of initial clinical experiences on students' perceptions of the profession. Research using a perception of nursing inventory demonstrated that sophomore students entered nursing valuing the profession and with positive perceptions of practice. They generally maintained these views through their first clinical experiences. The students had less positive perceptions about public opinions of nursing that were also unchanged after a semester of classroom and clinical experiences. Although scores on the nursing practice and nursing value scales of the inventory did not differ significantly from initial scores after one semester of clinical experience, the majority of students believed their perceptions changed after their first clinical experiences.

Key Words Image of Nursing--Perceptions of Nursing Practice--Nursing Students--Valuing of Nursing

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THE CURRENT SHORTAGE OF PRACTICING NURSES has been likened to a perfect storm, the result of a convergence of forces including increased demand, decreased supply, and unsatisfactory work environments (1). It remains at the forefront of health-care-related issues in the United States today. Although enrollments in nursing programs are increasing, they are not sufficient to meet projected needs, especially given the high number of nurses who will soon reach retirement age (2,3). Therefore, retaining students who enter nursing programs through graduation and entry into the nursing workforce is an important goal. * How students perceive the nursing profession upon entry into a nursing education program, and whether their perceptions change as they experience the world of nursing firsthand, may provide clues about their decisions to remain in nursing and their selection of practice settings after graduation. This research study was designed to investigate student perceptions about the value and practice of nursing and how the public values the profession early in the students' nursing education and six months later. Three research questions were asked:

* What are sophomore baccalaureate students' perceptions of the nursing profession prior to their first classroom and clinical experiences?

* What factors may have influenced the formation of these perceptions?

* In what ways do students' perceptions of the nursing profession change following their first classroom and clinical experiences?

Literature Review A review of the literature revealed few studies that addressed American nursing students' perceptions about the nursing profession. However, some pertinent studies were conducted in countries outside the United States. In an investigation of British nursing students' general perceptions about nursing, Spouse (4) found that students enter nursing with personal frameworks that are either strengthened or altered, depending on the support they receive from others. Students who left the nursing program were reported to more often hold stereotypical views of the profession.

Watson, Deary, and Lea used the Nursing Dimensions Inventory (NDI) and Caring Dimensions Inventory (CDI) to investigate perceptions among Scottish nursing students (5). Respondents rated the importance of specific bedside nursing skills as being representative of either nursing or caring. Upon entering a nursing program, students tended to view caring and nursing as separate entities; after 12 and 24 months of nursing education, they viewed them as more similar. They also became less idealistic about the profession during the time they spent in the nursing education program.

Watson and colleagues also used the NDI to investigate whether there were differences in how nursing students, non-nursing students, professional nurses, and patients in the United Kingdom and Spain perceived the importance of specific aspects of direct nursing care (6). They found that perceptions of what constituted "important" direct care nursing behaviors were highly similar across groups (except for a diabetic patient population), but that there was less agreement among groups about "unimportant" nursing behaviors or roles.

In another international study, Karaoz found that at the beginning of the nursing program, Turkish students defined nursing in a way that reflected a narrow, traditional view of the profession (7). After these students completed their initial nursing course, their definitions reflected a broader understanding of the roles of nurses in caregiving and in protecting and improving health.

Cook, Gilmer, and Bess conducted one of the few investigations of student perceptions of nursing in the United States (8). They asked beginning nursing students to define nursing and categorized their narrative responses. Students commonly defined nursing as a verb, using terms such as caring, nurturing, teaching, and implementing. Students who used nouns to characterize nursing most often described it as a profession, holistic system, connecting system, and delivery system. Students also identified nursing as a transaction, identifying roles of promotion of health, treatment of illness, and prevention of illness. The authors reported that students had a wide range of preexisting perceptions about nursing.

To date, no identified publications have addressed students' perceptions about the value of nursing as a profession, the importance of nursing roles, or the public's valuing of nursing. This research study was undertaken to fill this gap.

Method The Perceptions of Professional Nursing Tool (PPNT), which measures the perceptions of nursing among nurses, health care professionals, and health care consumers (9), was modified for use with nursing students. The original PPNT instrument included 32 items measuring perception of nursing practice and valuing of nursing on a five-point agreement scale, with reported reliability alphas of .84 for the Practice scale and .79 for the Value scale.

The PPNT was initially adapted for use with nursing students by removing items that did not apply to the student population and rewording several questions to improve clarity. Three questions addressing the dynamic nature of nursing and career diversity were added, resulting in 27 forced-choice items, including 13 items in the Practice subscale and 14 items in the Value subscale. Free response questions were also added. These addressed experiences that have shaped student perceptions of nursing, reasons for pursuing a nursing career, and student-reported changes in perceptions about nursing from first to second inventory.

The adapted inventory was tested with nursing students at a large mid-Atlantic land-grant university at the beginning of their sophomore year, prior to their experiencing the first nursing concepts and clinical applications courses. Students were tested a second time after they had experienced six months of classroom instruction and direct patient care. A standard coefficient alpha was used to examine internal consistency, with resulting overall alphas of .80 for the first inventory administration and .95 for the second. The coefficient alphas for the Practice subscale were .73 and .89 for first and second inventory administration, respectively. Reliability for the Value subscale was .67 and .90 for the first and second administration. Students appeared to become more consistent in their responses over time (10).

Based on an analysis of data from the initial use of the adapted PPNT inventory, additional revisions were made to the instrument. A separate subscale (Public Valuing) containing items measuring student perceptions of the public's valuing of the nursing profession was added. Questions for this subscale mirrored questions that measured students' valuing of the profession. A question relating to student perceptions of other health care professionals' valuing of nursing was removed from the list of subscale items as it was outside the realm of the three subscales identified. It was included as a separate item on the instrument. These revisions increased the number of forced-choice items within the subscales from 27 to 37. (See Sidebar on the following page for item content.) Institutional review board approval was obtained prior to the beginning of data collection.

The revised inventory was administered to sophomores at the beginning of their initial nursing concepts course and prior to clinical learning experiences. Students were given both verbal and printed information about the investigation, and provided informed consent prior to completing the initial inventory. After students had experienced approximately six months of classroom instruction and clinical rotations, they completed the inventory a second time. Inventories were marked with identifiers that protected students' anonymity while allowing comparison of individuals' responses to the two administrations.

Results DEMOGRAPHIC DATA Eighty-five students completed the inventory in the first semester and 74 in the second. Matching of identifiers created 70 data pairs. Eighty-nine percent of the respondents were 25 years old or younger, 87 percent were female, and 78 percent reported working in health care themselves or having a family member who worked in health care.

Students most frequently reported choosing a career in nursing because of "wanting to help others/make a difference" (46 percent, n = 34), followed by "having had positive personal experiences/role models in nursing" (16 percent, n = 12). The availability of a variety of career opportunities was identified by 12 percent (n = 9) of students. Other reasons for choosing nursing, including job security/salary, interest in nursing, and challenging/rewarding career, were identified by 5 percent of respondents or fewer. Students most frequently identified "pursuing further education" as a career goal (47 percent, n = 35), followed by "doing one's best in nursing/making a difference" (26 percent, n = 19) and "specializing in a nursing field" (7 percent, n = 5).

INTERNAL CONSISTENCY OF THE INSTRUMENT A standard coefficient alpha was used to examine internal consistency. The overall alpha was .89 for the first inventory administration and .96 for the second. The coefficient alpha for the Practice subscale was .78 and .94, for the first and second administrations, respectively. Reliability for the Value subscale was .91 and .95; for the Public Valuing subscale, it was .91 and .92.

STUDENT RESPONSE SCORES Likert scale data were coded numerically (1 = strongly disagree, 5 = strongly agree). Item means were calculated for all Likert response items. Means for the majority of the forced-choice items in both the Practice and the Value subscales were between 4 and 5, indicating a very positive view of nursing. However, response means for every question in the Public Valuing subscale were less than 4, ranging from 2.2 to 3.8 for the first inventory and 2.8 to 3.7 for the second. In addition, the mean score for the non-subscale item addressing student perceptions as to whether other health care professionals have respect for the nursing profession was also less positive. Inventory items with mean scores less than 4 appear in Table 1.

Subscale scores were calculated by adding individual response scores for each item within the subscales. Paired t-test comparisons revealed no significant differences in subscale scores between first and second datasets for any of the three subscales, but differences were identified in student responses to individual inventory items. On the second administration, students were more likely to agree with the statements "Nurses are responsible for positive patient outcomes," "Nurses should question incorrect MD orders," "Patient complications can be avoided when nurses do their jobs correctly," and "The public understands the complexity of nursing." At that time, they were less likely to agree with the statements "Nursing offers many career possibilities," "Nurses are intelligent and creative," and "The public sees nursing care as important as physical therapy." (See Table 2.)

Although there were significant differences between the first and second datasets for only a few items, the majority (95 percent, n = 61) of students reported that their perceptions of nursing had changed as a result of classroom and clinical experiences. The most common explanation for the change, "have a better understanding of the nursing role," was followed by "have learned about the complexity of nursing" and "have seen how hard nurses work."

Pairs of items within the Value subscale and the Public Valuing subscale asked essentially the same question, but from different perspectives. The Value subscale item asked for the student's own opinion about an issue; the Public Valuing subscale item asked for the student's opinion of public perception about the same issue. Paired t-test comparisons of mean subscale scores indicated that students' own valuing of nursing was significantly more positive than their perceptions of public valuing, upon entrance to the nursing program and after experiencing classroom and clinical instruction. (See Table 3, following page.)

Further comparisons revealed that student responses to the second inventory differed significantly according to what they reported as having the most influence over their perception of nursing. Students who believed that personal experience had the most influence over their perceptions tended to have the highest scores on the Value and Practice subscales. Those who stated that role models had the most influence on their perceptions had the lowest scores on all three subscales. And those who believed the media had the most influence over their perceptions had the highest scores on the Public Valuing subscale. (See Table 4.)

The students also had differing opinions about the factors that influenced their own perceptions of nursing and those they believed influenced public perceptions. They frequently identified the media as influencing public perceptions of nursing but not their own. Role models were identified as more influential on their own perceptions. Personal experiences were similarly identified as influencing opinions of both students and the public. (See Table 5.)

ANOVA comparison of student perceptions about where the public obtained information to form their opinion of nursing and Public Valuing subscale scores revealed significant differences in first-inventory responses. Students who believed that the public obtained information from personal experiences also believed that the public had a more positive opinion about nursing (mean subscale score 42.4) than those who believed the public got their information from the media (mean subscale score 37.9): T(64)2.2, p = .03. No significant differences were found in the second inventory administration data.

Responses to an open question about what students thought could be done to improve the public's image of nursing were categorized. The most common responses were: "Improve the media portrayal of nursing" and "Explain to/educate the public about how important nurses are in the field of health care."

Discussion The majority of participants in this study entered the nursing education program as a result of altruistic intentions, a factor commonly reported by other researchers (11,12). Many students had clear career goals of advanced practice in nursing. Upon entering the program, 40 percent planned to pursue advanced degrees; after six months, this figure climbed to 52 percent. Although advanced practice is a viable career option, it must be noted that a critical shortage exists in acute care bedside positions.

Students responding to the study entered the nursing education program with generally positive personal perceptions about the profession; their perceptions about how nursing is perceived by the public were significantly less positive. Although scores for the Value, Practice, and Public Valuing subscales did not change significantly over the six-month study period, an overwhelming majority of students reported that their own perceptions about nursing had changed following their first clinical experiences. They identified these changes as resulting from having a better understanding of "the nursing role," "the complexity of nursing," and "the high level of work involved in nursing."

Significant differences in student perceptions between the first and second survey were found for a few individual items. Some of the changes might be expected to result from educational experiences, such as higher levels of agreement with the statements that "RNs should question incorrect physician orders" and that "patient complications can be avoided when RNs do their jobs correctly."

Other changes on the second administration were not anticipated, including less agreement with the statements that "nursing offers many career opportunities," that "nurses are intelligent and creative," and that "the public sees nursing care as important as physical therapy." The factors contributing to these changes were not directly assessed. They may relate to a less idealistic perception of the nursing profession after exposure to the reality of nursing practice in a busy acute care setting.

As was found in the analysis of the initial PPNT adapted inventory (10), few students identified the media as influencing their own perceptions of nursing; however, many identified the media as influential in the public's perceptions. Comparison of student perceptions of the influences on the public's view and Public Valuing subscale scores demonstrated that students perceived the media as a negative influence on public perception. Their identification of "improving the media portrayal of nursing" as the predominant action that could be taken to improve the public's view of nursing supports this finding. Although efforts have been made to alter the media portrayal of the nursing profession, it is apparent that the negative perception about media influence persists, at least among this nursing student population.

Internal consistency of the modified PPNT inventory and the individual subscales was relatively high, particularly for the second survey administration. Similar results were found in analysis of data from the initial testing of the first adaptation of the PPNT (10). Perhaps clinical experiences contributed to increased student consistency in response to inventory items.

Limitations This study is limited in its generalizability in that respondents represented a convenience sample from one university. In addition, educational experiences may represent only one of the factors responsible for reported differences in student perceptions about nursing. Other uncontrolled variables may have contributed to the changes as well.

Further research is indicated to identify whether the perceptions held by students at the study university represent those of the general nursing student population. In addition, longitudinal investigations could provide information about changes in student perceptions about nursing between entry into a nursing education program and graduation from the program/entry into practice. Comparisons could also be made with the views of practicing nurses and with those who have recently left practice. Resulting data may have implications in relation to the nursing shortage crisis.

Conclusion When educators understand nursing students' perceptions of nursing prior to, during, and following their education programs, they can be more aware of potential disparities in students' ideals, expectations, and the reality of nursing practice. Having an understanding of the perceptions and goals of students and new graduates may provide information related to the nursing shortage.

Nurse educators and the nursing profession as a whole must attend to the perceptions held about our profession and take action to promote positive perceptions within the profession, among our future professionals, and among the public. Accurately informing both students and the public of the roles, responsibilities, and opportunities within the profession may promote a higher degree of student satisfaction with their career choice and contribute to student retention and entry into nursing practice.

References

(1.) Bleich, M. R., & Hewlett, P. O. (2004). Dissipating the "perfect storm": Responses from nursing and the health care industry to protect the public's health. Online Journal of Issues in Nursing, 9(2), 1-15.

(2.) American Association of Colleges of Nursing. (2004). Nursing shortage fact sheet. Washington, DC: Author. [On-line]. Available: www.aacn.nche.edu/Media/Backgrounders/shortagefacts.htm.

(3.) American Association of Colleges of Nursing. (2003, December 22). Thousands of students turned away from the nations' nursing schools despite sharp increase in enrollment. Washington, DC:Author. [Online]. Available: www.aacn.nche.edu/Media/NewsReleases/Archives/2003/enr103.htm.

(4.) Spouse, J. (2000). An impossible dream? Images of nursing held by pre-registration students and their effect on sustaining motivation to become nurses. Journal of Advanced Nursing, 32(3), 730-739.

(5.) Watson, R., Deary, I. J., & Lea, A. (1999). A longitudinal study into the perceptions of caring and nursing among student nurses. Journal of Advanced Nursing, 29(5), 1228-1237.

(6.) Watson, R., Deary, I.J., Hoogbruin, A. L., Vermeijden, W., Rumeu, C., Beunza, M., et al. (2003). Perceptions of nursing: A study involving nurses, nursing students, patients and non-nursing students. International Journal of Nursing Studies, 40, 133-144.

(7.) Karaoz, S. (2004). Change in nursing students' perceptions of nursing during their education: The role of the Introduction to Nursing course in this change. Nurse Education Today, 24(2), 128-135.

(8.) Cook, T. H., Gilmer, M.J., & Bess, C.J. (2003). Beginning students' definitions of nursing: An inductive framework of professional identity. Journal of Nursing Education, 42(7), 311-317.

(9.) Rocchiccioli, J. (1992). A study to develop an instrument to assess the perceptions of professional nursing. Unpublished doctoral dissertation, Virginia Commonwealth University, Richmond.

(10.) Schaffer, A. J., & K. Sand-Jecklin (2004). The impact of first clinical experiences on BSN students' perceptions of the nursing profession. Unpublished manuscript, West Virginia University, Morgantown.

(11.) Johnson, S., & Peterson, C. (1990). Baccalaureate students' reasons for choosing nursing and perceptions of the profession. Prairie Rose, 59(2), 20.

(12.) Barribal, K. L., & While, A. E. (1996). The similarities and differences between nurses with different career choice profiles: Findings of an interview survey. Journal of Advanced Nursing, 23, 380-388.

Sidebar

VALUING SUBSCALE ITEMS

* Patients select a hospital based on nursing care

* Nursing care is as important as physical therapy

* Nurses work hard

* Nursing is a profession

* I respect the profession of nursing as much as the profession of law

* The public has a positive image of nursing

* Nursing is very complex

* Nursing is a rapidly changing profession

* Nurses are very organized

* The nurse is an important member of the health care team

* Nursing is diverse and offers many different career possibilities

* Nursing is challenging and rewarding

* Nurses are intelligent and creative

PRACTICE SUBSCALE ITEMS

* Nurses with bachelor's degrees are better prepared to enter the profession than those with associate degrees or diplomas

* Teaching health promotion and disease prevention in the community is as much a nursing responsibility as are other nursing roles in patient care

* Nurses have considerable autonomy in their practice

* Nurses are directly responsible for positive outcomes in their patients' health

* Nurses should question medical orders that they judge to be possibly incorrect

* Nurses need to learn skills that overlap with other health care staff skills

* Optimum nursing care requires regular patient assessment

* Patient education is an important part of nursing practice

* Most patient complications are avoided when nurses do their jobs correctly

* Nurses improve the quality of patient care by planning the care specific to each patient and carrying out the identified plan

* Physician/nurse collaboration improves health outcomes for patients

PUBLIC VALUING SUBSCALE

* The public considers nursing care to be as valuable as physical therapy

* The public believes that nurses work hard

* The public thinks of nurses as professionals

* The public respects the profession of nursing as much as the profession of law

* The public understands the complexity of nursing

* The public perceives nursing as a rapidly changing profession

* The public believes nurses are organized

* The public believes the nurse to be an important member of the health care team

* The public perceives nursing to be a diverse profession with many career possibilities

* The public sees nursing as a challenging and rewarding health care career

* The public values the intelligence and creativity of nurses

ITEMS NOT WITHIN A SUBSCALE

* Other health care professionals have respect for the nursing profession

* What has had the most influence over your perception of the nursing profession?

* Where do you think the public gets its information to form opinions of nursing?

Karl E. Sand-Jecklin, EdD, MSN, RN, is an assistant professor at the West Virginia University School of Nursing, Morgantown. Angela J. Schaffer, BSN, is a staff nurse at Ruby Memorial Hospital, Morgantown, West Virginia. For more information, contact Dr. Sand-Jecklin at ksandjecklin@hsc.wvu.edu.
Table 1. Inventory Items with Response Means < 4.0

Item Adm 1 Adm 2

PRACTICE SUBSCALE
BSN nurses are better prepared than ADN 3.9 3.2
 or diploma nurses
Nurses have autonomy in practice 3.8 3.9
Patient outcomes are related to RN care 3.9 4.0
Patient complications can be avoided when 3.6 4.0
 RNs do job well

VALUE SUBSCALE
Patients select hospitals for nursing care 3.1 3.2
RNs are very organized 3.9 3.9

PUBLIC VALUING SUBSCALE
Public sees nsg care as important as physical therapy 3.5 3.3
Public thinks nurses work hard 3.6 3.6
Public thinks of nurses as professionals 3.8 3.6
Public respects nursing as much as law 2.7 2.8
Public understands the complexity of nursing 2.2 2.6
Public sees nursing as rapidly changing 3.3 3.2
Public believes nurses are organized 3.3 3.3
Public sees nurses as important members of 3.7 3.7
 health care team
Public perceives the diversity and career 3.5 3.3
 opportunities in nursing
Public sees nursing as challenging and rewarding 3.3 3.4
Public values intelligence and creativity of nurses 3.2 3.3

NON-SUBSCALE ITEM
Other health care professionals respect nursing 3.9 3.6

Table 2. Significant Differences in Student Response to Individual
Items Between First/Second Inventory Administration

 Mean Scores t df p

Nurses are responsible for Adm 1: 3.9 -2.7 69 .008
positive patient outcomes Adm 2: 4.3

Nurses should question Adm 1:4.3 -2.3 69 .03
incorrect MD orders Adm 2:4.6

Patient complications can be Adm 1:3.6 -2.9 68 .004
avoided when nurses do job correctly Adm 2:4.0

Nursing has many career Adm 1:4.9 2.40 69 .02
possibilities Adm 2:4.6

Nurses are intelligent/creative Adm 1:4.7 3.00 69 .004
 Adm 2:4.4

Public sees nursing care as Adm 1:3.5 2.00 69 .05
important as physical therapy Adm 2:3.3

Public understands the Adm 1:2.2 -2.44 69 .02
complexity of nursing Adm 2:2.5

Table 3. Comparison of Paired Student Valuing and
Public Valuing of Nursing Subscale Means

 Mean df t Sig

Value subscale adm. 1 4.51 74 12.45 .000
Public Valuing subscale adm. 1 3.33

Value subscale adm. 2 4.43 74 10.53 .000
Public Valuing subscale adm. 2 3.30

Table 4. Student Perception of Factors Influencing Perceptions
of Nursing vs. Subscale Scores, Second Inventory Administration

 Factors M F(df) p

Value Subscale Media 52.4 (5) 3.2 (2,67) .05
 Role Models 49.7 (23)
 Personal Experience 55.2 (70)

Practice Subscale Media 56.2 (56) 3.6 (2,67) .03
 Role Models 52.1 (23)
 Personal Experience 58.3 (70)

Public Valuing Media 46.0 (5) 3.2 (2,67) .05
 Subscale Role Models 36.7 (23)
 Personal Experience 40.7 (70)

Table 5. Differences in Student Opinion about Role of Media, Role
Models, and Personal Experience on Personal and Public Perceptions
of Nursing

 Personal Influence Public Influence

Media (dataset 1) 7 percent (n = 5) 34 percent (n = 33)
Media (dataset 2) 7 percent (n = 5) 51 percent (n = 38)

Role models (dataset 1) 34 percent (n = 25) 0 percent (n = 0)
Role models (dataset 2) 31 percent (n = 23 0 percent (n = 0)

Personal experience
 (dataset 1) 42 percent (n = 31) 45 percent (n = 33)
Personal experience
 (dataset 2) 57 percent (n = 42) 45 percent (n = 33)

 Chi-square Sig

Media (dataset 1) 21.3 .00
Media (dataset 2) 27.3 .00

Role models (dataset 1) * .00
Role models (dataset 2) * .00

Personal experience
 (dataset 1) 0.0 1.00
Personal experience
 (dataset 2) 2.1 .15

* Chi-Square not calculated due to zero
in cells--exact significance provided
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Author:Sand-Jecklin, Karl E.; Schaffer, Angela J.
Publication:Nursing Education Perspectives
Date:May 1, 2006
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