Nursing students' professional image in the Covid-19 pandemic in Turkey: A cross-sectional study.

BACKGROUND: Nursing students' professional perceptions are affected by the environment they live in. Nursing students think that the nursing profession is important during the pandemic.
PURPOSE: This descriptive, cross-sectional study was conducted to determine the nursing students' professional image perceptions and the affecting factors during the Covid-19 pandemic in Turkey.
METHODS: The research population consisted of all nursing students (N = 750) of two universities in Turkey. The research data were collected using a personal information form and the Scale for the Image of Nursing Profession (SINP).
RESULTS: Of the students, 76.4% were not infected with Covid-19, 30.8% had an individual in their family infected with Covid-19; 34% had an immediate family member who died of Covid-19; 99.4% thought that the nursing profession is important during the Covid-19 pandemic. A statistically significant difference was found between the place where the students live and the SINP (p < .05).
CONCLUSION: The students' image perceptions toward the nursing profession were found to be at a good level. This indicates that image perception toward nursing profession has increased during the pandemic. It can be said that the place where the students are in the pandemic process and their thoughts about the nursing profession affect their professional image perceptions.

INTRODUCTION

Nurses work to protect, maintain and develop the health of individuals, families, and societies all over the world. Playing a significant role in carrying out healthcare services, nursing constitutes a keystone of the healthcare system in providing quality care. Medical treatment is not sufficient alone, therefore training nurses, who are specialized in their area, have the ability to think critically, and have developed problem solving skills, is necessary for all societies to acquire the importance of the protective health into the society and to reduce healthcare costs.

As a profession, nursing is influenced by education, professional skills, ethical values, and social structures that the nurses provide care for. Students' perceptions regarding a profession are effective for them to choose that profession and make their career accordingly. Nursing students receive theoretical and practical education for many years to be able to fulfill their profession. Undergraduate nursing education began in 1955 in Turkey. Today, the number of universities providing nursing education in higher education has reached 124. During 4 years of nursing education, together with theoretical courses, students receive practical education in the field. Master's degrees in nursing were offered for the first time in 1968 and the doctoral program in the same field was established in 1972 in Hacettepe University. There are 69 universities which currently provide master's degree program and 35 universities which provide doctoral program. Nurses become more competent through education in these upper‐levels, hence they can put their knowledge and experiences into practice, which can increase the quality of care.

The image of nursing is constituted by individuals' views and attitudes toward the nursing profession. Occupational image is effective in individuals choosing that profession. A positive professional image increases individuals' morale and motivation and contributes to their work satisfaction.

The studies conducted have indicated that the image of nursing is directly related to the individuals' perspectives of the nursing profession in the society. , Society's perceptions regarding the image of nursing affect the students' academic success and their self‐conceptions. A study conducted with nursing students found their image perceptions toward the nursing profession to be at medium level. It is clear that the characteristics of the perception of nursing image are influenced by working conditions and appearance.

As in the rest of the world, developments in the healthcare system in Turkey within the last decade have changed the role of nurses in a significant way. These developments have imposed more responsibilities on the nursing profession and its education. Understanding the nature of nursing has gained more importance due to ever‐changing world and the Covid‐19 pandemic. Problems regarding nurses' job descriptions, work burden, and patient care have increasingly received more attention. Nurses who have struggled on the front line during the Covid‐19 pandemic have successfully managed the process. Nurses who fought against time with the increasing number of cases during the Covid‐19 pandemic have played an effective role in providing holistic healthcare to help in the recovery process of the patients. They have taken on tasks and responsibilities of following close attention to the vital signs of the patients, maintaining the treatments of those who need oxygen support, applying closed‐system aspiration in necessary cases, and providing proper use of protective equipment to protect both them and other patients against the risk of infection. Nurses have continued to provide professional care by taking part in the public health education of preventing infection and reducing its prevalence. They have been regarded as the heroes of the pandemic all over the world, and their importance has been understood in a greater way by the societies.

This study aimed to determine the nursing students' image perceptions toward their profession during the Covid‐19 pandemic in Turkey.

The research questions are as follows:

What are the perceptions of nursing students toward their profession during the Covid‐19 pandemic?

What are the factors affecting the professional image perceptions of nursing students during the Covid‐19 pandemic?

METHODS

Research population and sample

The research population consisted of all nursing students (N = 750) of two universities in Turkey. Nursing education includes 4 years of education. It was aimed to reach all students studying in this department. Using the sample formula, the required sample size for this population, which is not in a homogeneous structure, is within the 95% confidence interval, with a sampling error of ±5% n = 750 (1.96) 2 (0.2) (0.8)/(0.5) 2 (750 – 1) + (1.96) 2 (0.2) (0.8) = 138 was calculated as. The study was carried out between March 13 and April 20, 2021 with 474 students who accepted to participate in the study. The data were collected with the “personal information form” and “the Scale for the Image of Nursing Profession (SINP)” prepared through Google forms. The questionnaire link was sent to the participants via institutional e‐posta adress. By receiving and clicking the link, the participants were automatically directed to the information of the study and the consent form. After accepting to participate, the personal information form and the SINP form were filled out. The participants who studied in the nursing department and volunteered to provide informed consent were included in the study.

Data collection tools

Personal information form

The form, which was prepared by the researcher on the basis of literature review, includes sociodemographic characteristics and 15 questions. , ,

SINP

Developed by Dost and Bahçecik, this scale consists of 42 items and six subdimensions that are Professional Qualities (11 items), Working Conditions (10 items), Gender (8 items), Education (5 items), Professional Status (5 items), and Appearance (3 items). The Lawshe technique was used to determine content validity rates. Explaining 63.59% of the total variance after factor analysis. It was observed that 42 items were collected in 6 subdimensions. It is a 5‐point‐Likert‐type scale, with the statements of “definitely agree” (5) and “definitely disagree” (1). The minimum obtainable score from the scale is 42, and the maximum is 210. While a score of 42–75 indicates a very weak image perception, 76–109 indicates weak, 110–143 moderate, 144–177 good, and 178–210 very good image perception. As the score from the scale increases, the professional image perception increases accordingly. The Cronbach's α coefficient, which was .91 in the original validity and reliability study of the scale, was found to be .87 in this study.

Data analysis

Data analysis was done using the SPSS 20.0 software. To evaluate the data, frequency, percentage, mean, and standard deviation, the Mann–Whitney U and Kruskal–Wallis tests were used. For the results, p < .05 was accepted as statistically significant.

Data analysis was performed with IBM SPSS 22 program. Descriptive statistics, mean and standard deviation for continuous variables; for categorical variables, it is presented as frequency and percentage. It was determined that the scores obtained from the scale and its subdimensions did not show normal distribution. For this reason, Mann–Whitney U‐test was used in paired group comparisons and Kruskal–Wallis test was used in comparisons with more than two groups. Statistical significance value was taken as p < .05.

Ethical considerations

To conduct the research, Ethics Committee Approval (date: 3.12.2021 with the decision number of 2021‐6) from the Noninvasive Clinical Research Ethics Committee of the related university and written consent through online forms were obtained from the students who participated in the research.

RESULTS

The SINP mean score of the students was found to be 167.36 ± 15.78. The scale's subdimension scores are presented in Table 1.

Table 1

The distribution of the students' mean scores for SINP and its subdimensions (N = 474)

The scale and subdimensions	Mean scores (mean ± SD)
Professional qualities	51.37 ± 5.30
Working conditions	43.76 ± 4.69
Gender	20.51 ± 5.54
Education	22.56 ± 3.13
Professional status	17.31 ± 4.66
Appearance	11.82 ± 2.56
Scale total	167.36 ± 15.78

Abbreviation: SINP, Scale for the Image of Nursing Profession.

Of the students, 29.5% (n = 140) were 20 years old; 81% (n = 384) were female and 19% (n = 90) were male; 85.2% (n = 405) lived with their family and 7.8% (n = 37) lived in the dormitory; 20% (n = 95) had an income less than their expenses and 57.3% (n = 319) had an income equal to their expenses; 82.3% (n = 390) had a nuclear family structure; 37% (n = 177) had one sibling; 67.5% (n = 320) graduated from an Anatolian high school and 18.6% (n = 88) graduated from a vocational school of health. Of them, 90.3% (n = 428) did not have any diagnosed physical disorders; 76.4% (n = 362) were not infected with Covid‐19, whereas 30.8% (n = 146) had an individual in their family infected with Covid‐19; 10.8% (n = 51) were employed; 34% (n = 161) had an immediate family member who died of Covid‐19; and 99.4% (n = 471) thought that the nursing profession is important during the Covid‐19 pandemic (Table 2).

Table 2

Personal characteristics of students (N = 474)

Personal characteristics	n	%
Age
18 or younger	35	7.4
19	103	21.7
20	140	29.5
21	93	19.6
22 or older	103	21.7
Gender
Female	384	81.0
Male	90	19.0
Where do you live?
At home with my family	405	85.4
At home with my friends	13	2.7
In the dormitory	37	7.8
At home with my relatives	6	1.3
At home alone	13	2.7
Perceived income level
Income is less than expenses	95	20.0
Income is equal to expenses	319	67.3
Income is higher than expenses	60	12.7
Family type
Nuclear family	390	82.3
Extended family	72	15.2
Fragmented family	11	2.3
Missing data	1	0.2
Number of siblings
I do not have any siblings	13	2.7
One sibling	177	37.3
Two siblings	137	28.9
At least three siblings	147	31.0
Type of the school graduated
Vocational school of health	88	18.6
Science high school	25	5.3
Anatolian high school	320	67.5
Other	41	8.6
Is there anyone from your immediate family who works as a nurse?
Yes	245	51.7
No	229	48.3
Do you have any diagnosed physical disorders?
Yes	46	9.7
No	428	90.3
Have you been infected with Covid‐19?
Yes	48	10.1
No	362	76.4
I don't know	64	13.5
Do you have anyone in your family who has been infected with Covid‐19?
Yes	146	30.8
No	328	69.2
Are you employed?
Yes	51	10.8
No	423	89.2
Do you have any immediate family member who died of Covid‐19?
Yes	161	34.0
No	313	66.0
Do you think the nursing profession is important during the Covid‐19 pandemic?
Yes	471	99.4
No	3	0.6
Total	474	100.0

A statistically significant correlation was found between the scale total scores and the place lived (p < .05) among the groups of students at home with their family, at home with their relatives, at home with their friends, at home alone, or in the dormitory. While the total scale scores of those who stayed at home with their friends were the highest (171.07 ± 21.06), the mean score of those who stayed at home with their relatives was the lowest (133.33 ± 35.06). The scale total score became statistically significant with the thought that the nursing profession is significant during the Covid‐19 pandemic; and the mean score of those who gave the answer “yes” to the question “Do you think the nursing profession is important during the Covid‐19 pandemic?” was found to be higher (p < .05) (Table 3).

Table 3

The comparison of the students' SINP total mean scores and some personal characteristics (n = 474)

	N	Mean	SD	p
Age
18 or younger	35	163.5714	19.92528
19	103	167.3981	15.84071
20	140	166.1143	17.59377	.183
21	93	169.9140	13.07225
22 or older	103	168.0388	13.54435
Gender
Female	384	167.3854	14.37424	.946
Male	90	167.3000	20.87709
Where do you live?
At home with my family	405	168.0716	15.13658
At home with my friends	13	171.0769	21.06522
In the dormitory	37	166.6486	10.99044	.000*
At home with my relatives	6	133.3333	35.06375
At home alone	13	159.5385	10.79055
Perceived income level
Income is less than expenses	95	166.5579	15.94653
Income is equal to expenses	319	167.1567	15.85272	.582
Income is higher than expenses	60	169.7833	15.22720
Family type
Nuclear family	390	167.8205	14.57799
Extended family	72	165.7500	20.87910	.765
Fragmented family	11	162.0909	19.31038
Number of siblings
I do not have any siblings	13	168.9231	8.93925	.818
One sibling	177	168.5819	12.11476
Two siblings	137	168.0730	14.42253
At least three siblings	147	165.1156	20.56414
Type of the school graduated
Vocational school of health	88	170.0341	11.29281	.636
Science high school	25	160.5200	30.70304
Anatolian high school	320	167.2625	15.29869
Other	41	166.6585	13.89534
Is there anyone from your immediate family who works as a nurse?
Yes	245	167.7143	16.12147	.696
No	229	167.0000	15.45367
Do you have any diagnosed physical disorders?
Yes	46	167.8913	13.65646	.750
No	428	167.3131	16.01522
Have you been infected with Covid‐19?
Yes	48	169.9375	12.98838
No	362	167.3923	15.62319	.537
I don't know	64	165.3125	18.38553
Do you have anyone in your family who has been infected with Covid‐19?
Yes	146	168.4247	13.93524	.310
No	328	166.8994	16.54700
Are you employed?
Yes	51	165.9020	17.80815	.507
No	423	167.5461	15.54285
Do you have any immediate family member who died of Covid‐19?
Yes	161	167.7764	16.56426	.642
No	313	167.1597	15.39918
Do you think the nursing profession is important during the Covid‐19 pandemic?
Yes	471	167.5329	15.69329	.007*
No	3	141.6667	9.50438
Total	474	100.0

Note: Test: The Mann–Whitney U‐test was used in pairwise groups and the Kruskal–Wallis test for three or more categorical groups, *and bold values denote statistically significant p < .05.

Abbreviation: SINP, Scale for the Image of Nursing Profession.

No statistical significance was found between working conditions, gender, professional status, and appearance with the thought that the nursing profession is important during the Covid‐19 pandemic (p  > .05). The subdimension of professional qualities has statistical significance with the thought that the nursing profession is important during the Covid‐19 pandemic (p  < .05); and the mean score of the individuals who gave the answer “yes” to the question was found to be higher (51.43 ± 5.25). The gender, education, and scale total score had statistical significance with the thought that the nursing profession is important during the Covid‐19 pandemic, and the mean score of those who gave the answer “yes” to the question was found to be higher (p  < .05) (Table 4).

Table 4

The variation of SINP scores according to the thought of the nursing profession to be important during the Covid‐19 pandemic

	N	Mean	SD	p
Professional qualities
Yes	471	51.4331	5.25188
No	3	41.6667	5.03322	.007*
Total	474	51.3713	5.30241
Working conditions
Yes	471	43.7877	4.69059
No	3	40.0000	4.35890	.092
Total	474	43.7637	4.69392
Gender
Yes	471	20.5308	5.55194
No	3	18.6667	3.21455	.554
Total	474	20.5190	5.54023
Education
Yes	471	22.6178	3.04408
No	3	15.0000	7.93725	.015*
Total	474	22.5696	3.13684
Professional status
Yes	471	17.3312	4.66502
No	3	15.3333	5.13160	.424
Total	474	17.3186	4.66486
Appearance
Yes	471	11.8323	2.57308
No	3	11.0000	1.73205	.444
Total	474	11.8270	2.56823
Scale total
Yes	471	167.5329	15.69329
No	3	141.6667	9.50438	.007*
Total	474	167.3692	15.78974

Note: Test: Mann–Whitney U, *and bold values denote statistically significant p < .05.

Abbreviation: SINP, Scale for the Image of Nursing Profession.

DISCUSSION

The obtainable scores from the SINP range between 42 and 210. While a score of 42–75 indicates a very weak image perception, 76–109 indicates weak, 110–143 moderate, 144–177 good, and 178–210 very good image perception. In this study, the SINP mean score was at a good level at 167.36 ± 15.78. In other studies, the SINP mean score was found at a moderate level. , , , It is clear that image perception toward the nursing profession has increased during the Covid‐19 pandemic. Nurses who have fought against time with the day‐to‐day increase in case numbers throughout the Covid‐19 pandemic have played an effective role in providing holistic healthcare to help in the recovery of their patients.  All around the world, nurses have been regarded as the heroes of the pandemic, and their importance has increased in the society.

The characteristics of the nursing profession are influenced by working conditions, education, gender, professional qualities, professional status, and appearance. As healthcare professionals, nurses need to have some qualifications to successfully fulfill their professional roles. These qualifications include having scientific knowledge, being able to apply therapeutic communication, creativity and being able to think critically. In this study, the professional qualities subdimension had the highest mean among the subdimensions. In the development of students' image perceptions regarding the nursing profession, professional qualities are considered important. It is seen that after the “professional qualifications” subdimension, the “working conditions” subdimension and then the “education” subdimension received high scores. In other studies, the subdimension of professional qualities was higher in the constitution of professional image perception. ,

This study showed that the score of appearance subdimension was lower compared to other subdimensions of SINP. In the studies conducted, nurses were expected to be cheerful, well‐groomed, and polite. , In terms of the subdimension of appearance, nurses' characteristics such as cheerfulness and being well‐groomed did not leave sufficiently positive impressions on the students during their observation.

The SINP mean scores of female and male students were found to be similar. This indicates that perceptions of male students regarding the nursing profession have changed and they do not regard nursing as a female profession, which is supported by the studies conducted in recent years. , Examining the number of students in the Council of Higher Education, there is an increasing number of male students who continue their nursing education. While the number of students who studied in the nursing faculties was 3072 in the 2018–2019 academic year, it increased to 3535 in the 2019–2020 academic year.

The environment where the students lived during their education affected their image perceptions toward the nursing profession. These perceptions were found to be higher for the students who shared a house with their friends compared to the students who lived with their relatives. Therefore, we can say that living with friends can positively affect individuals' image perceptions of the nursing profession. The nursing education process contributes to the students' nursing profession image perception in a positive way.

Considering the nursing profession important during the Covid‐19 pandemic has influenced image perception toward the nursing profession. The studies conducted have found that students' professional identity perception levels have increased during the Covid‐19 pandemic, which has positively influenced the image of the nursing profession. , During the pandemic, the media presenting the work of nurses and governments’ efforts have increased the visibility of nurses all over the world and contributed to the image of nursing. In Turkey, nurses have been able to raise their voice through nursing associations and social media. The Turkish Nurses Association has closely followed the Covid‐19 pandemic at the national and international level, and has become effective in solving the problems that nurses have faced with during the management of the process. ,

LIMITATIONS

This study was conducted with the students who studied in the nursing departments of two universities in Turkey which is the limitation of the research. Evaluation of the findings of this study should consider that its sample was an on‐line sample of individuals who have access to the internet, and consists of students who have more social connections, even if they are virtual.

CONCLUSIONS

The image perception of nursing students toward the nursing profession was found to be at a good level. It is clear that image perception toward the nursing profession has increased during the Covid‐19 pandemic. In the development of students' image perceptions regarding the nursing profession, professional qualities are considered important. The Covid‐19 pandemic is not only a crisis but also an opportunity for nursing students to increase their professional image. Student nurses are recommended to behave professionally while providing care to their patients and promote their professional and personal developments by continuous reading.

In order for the nursing profession to take its rightful place in the future, it is important to improve the nursing students' self‐conceptions, and develop strategies to contribute to their professional image perceptions in the society in a positive way.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.