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High school seniors' perceptions of nursing Grieve, Anna Marguerite 1991

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High School Seniors' Perceptions of Nursing by Anna Marguerite Grieve B.S.N., The University of British Columbia, 1978 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF T H E REQUIREMENTS FOR T H E D E G R E E OF MASTER OF SCIENCE IN NURSING in T H E F A C U L T Y OF G R A D U A T E STUDIES The School of Nursing We accept this thesis as conforming to the required standard T H E UNIVERSITY OF BRITISH COLUMBIA July 1991 © Anna M. Grieve, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) ii A B S T R A C T Declining enrollments in nursing programs, combined with the negative image of nursing as a profession, stimulated the author to investigate the current status of the nursing profession as viewed by a group of senior high school students. Using a questionnaire, subjects were asked to identify those areas they believed nurses to work in, and those job activities nurses performed. As well, they were asked a series of questions related to educational requirements of nurses and whether or not they would consider a nursing career, and, if not, possible reasons for their decision. In the final portion of the questionnaire students responded to statements on occupational image and occupational preference. Findings revealed that students had definite perceptions of nursing. While some of these were accurate, others were not consistent with the nature of the nursing profession today. Results of this study can be used by the nursing profession to plan a suitable advertising campaign with the primary purpose of informing young people about the career opportunities within the nursing profession, as well as dispelling many of the old myths related to the profession. Such efforts will help students perceive of the nursing profession positively. This in turn will encourage more young people to pursue a nursing career and help to alleviate the critical nursing shortage experienced here in North America. iii T A B L E OF CONTENTS Abstract ii Table of Contents iii List of Tables v List of Figures vi Acknowledgements vii CHAPTER ONE: INTRODUCTION 1 Background to the Problem 1 Problem Statement 2 Purpose 3 Theoretical Framework 3 Self Concept 4 Occupational Image 4 Occupational Preference 4 Perceived Accessibility 5 Occupational Alternatives 5 Social Space 5 Occupational Aspiration 5 Application of Theoretical Framework 6 Research Questions 6 Significance for Nursing 7 Definition of Terms 7 Assumptions and Limitations 7 Overview of the Thesis Content 8 CHAPTER TWO: L I T E R A T U R E REVIEW 9 The Concept of Image 9 Image in the Media 10 Historical View of the Image of Nursing 11 Implications of the Negative Image 16 Summary of Literature Review 19 C H A P T E R T H R E E : M E T H O D S Design Sample Human Rights and Ethical Considerations Data Collection Procedures Data Collection Instrument Data Analysis C H A P T E R F O U R : P R E S E N T A T I O N A N D DISCUSSION O F FINDINGS Sample Characteristics Findings Related to Research Questions Research Question 1 & 2: Respondents Exposure to Nursing Research Question 3: Where Nurses Work Research Question 4: Responsibilities of Nurses Research Question 5: Education of Nurses Research Question 6: Changes to Nursing Research Question 7: Occupational Image Research Question 8: Occupational Preference Discussion of Findings 32 Knowledge of Nursing 33 Image of Nursing 33 Occupational Preference 34 C H A P T E R F I V E : S U M M A R Y , C O N C L U S I O N S , I M P L I C A T I O N S and R E C O M M E N D A T I O N S 36 Summary 36 Conclusions 40 Implications for Nursing Practice 40 Implications for Nursing Education 41 Recommendations for Research 42 R E F E R E N C E S 44 A P P E N D I C E S 48 Appendix A : Subject Information Letter 49 Appendix B: Data Collection Tool 50 LIST OF TABLES Table Page I. Information About Nursing 27 II. Use of the Counselling Service 28 III. Work Areas of Nurses 28 IV. Nursing Responsibilities 29 V. Education of Nurses 30 VI. Reasons for not Considering Nursing 31 VII. Reasons for Considering Nursing 31 VIII. Changes to Nursing 31 VI LIST OF FIGURES 1. Occupational Aspirations 3 vii ACKNOWLEDGEMENTS I would like to take this opportunity to recognize the contributions my children have made in encouraging me to complete this thesis. The warm words of encouragement, the cards, the hugs were appreciated. Thank you Kristen and Brandon.. Words can not express the gratitude I feel towards my husband, Alfred Heringa, who unfailingly stood by me when the going was rough. His nonjudgmental approach nurtured me when I needed it most. To my dear friends a big thank you. You were all so wonderful in your support of this endeavour. My deepest respect and admiration for the members of my thesis committee, Carol Jillings and Joanne Ricci. Thank you for your continued interest and technical assistance. What would I have ever done without your editing skills? 1 CHAPTER 1 Background to the Problem There is an acute shortage of registered nurses in North America (Baumgart, 1987; Naylor & Sherman, 1988). Combined with the declining enrollment of students in nursing programs (Naylor & Sherman, 1988; Ryten 1988) this acute shortage has far reaching implications for the health of the general population. The demand for nursing services is on the increase due to a number of factors such as the aging North American population, advances in health care technologies and the advent of new and varied health care programs (Baumgart, 1987; Kerr & McPhail, 1988). It is safe to assume that this demand for nursing services will continue to increase. Yet, there is a very real possibility that the nursing shortage will only worsen (McDaniel, 1986). Baumgart (1988) has reported that problems within the work setting including high levels of stress, poor hours, and the lack of professional autonomy contribute to problems with nurse retention. Turnover rates among practising registered nurses are high and are reported as "excessive in comparison to those for women in other fields" (Baumgart, 1988, p. 58). Health care delivery has become increasingly diversified (Kerr & MacPhail, 1988). No longer is the acute care hospital the major provider of health care. There has been growth in such programs as home care, outpatient services and ambulatory care facilities. These changes in the health care delivery system have meant an increased need for nurses (Kerr & MacPhail, 1988). The pool of available nursing students is on the decline as Canada's "baby boomers" approach mid life in well established careers (McDaniel, 1986). Nursing is no longer considered a "career of choice" among today's high school 2 graduates (Turner, 1990). A recent review of enrollment patterns within Canadian schools of nursing documents a declining enrollment (Baumgart, 1988). Similar trends have been documented in American nursing literature (Marriner-Tomey et al, 1990; Norby, 1987). Why are students failing to choose a career in nursing? Recruitment into nursing programs is a priority for the nursing profession. One way to begin to deal with recruitment issues is to identify what aspects of nursing's image as a profession deter students from pursuing a nursing career. There is little current documentation as to what students know about nursing and what they think of the profession as a whole. An understanding of these perceptions would help the nursing profession plan suitable, relevant recruitment strategies aimed particularly at high school students. This study focused on the perceptions that grade twelve high school students have of the nursing profession. Issues related to the image of nursing as a profession were studied through the use of a questionnaire. The identification of students' perceptions may lead to increased understanding of recruitment issues. Problem Statement The nursing profession relies on high school students as a potential source of new recruits into the profession. However, a number of contributing factors, such as increased career options and a decline in the image of nursing as a profession of choice, may have led to a decline in the number of high school students choosing to enter the nursing profession (Norby, 1987). The author is concerned that grade twelve students' perceptions of the nursing profession may not be accurate. These students may be unaware of the diverse roles and responsibilities which are inherent in nursing practice. At present, current research is not available which identifies how the nursing 3 profession is perceived by grade twelve students. With increasing concern related to the declining enrolment of students into nursing programs it is important to ensure that a group of potential recruits (high school students) perceive the nursing profession accurately. The nursing profession needs to know students' perceptions in order to plan and implement effective recruitment strategies. Therefore this study asks the research question, how do a group of grade twelve students perceive the nursing profession? The major purpose of this study was to explore the perceptions high school students (specifically grade twelve students) have in relation to the nursing profession. As well, this study helped to determine what sources students used to obtain information on the nursing profession, and identified their general knowledge of nursing. The theoretical framework utilized in this study is an adaptation of Gottfredson's (1981) theoretical model for occupational aspirations (see Figure 1). Self-Concept gender social class intelligence interests, values Purpose Theoretical Framework Occupational images sex type prestige level field Preferences (perceptions of job-self compatibility Range of acceptable occupational alternatives (social space) Perceptions of job accessibility (of opportunities & barriers Occupational Aspiration Stimulus to name one occupational title as a goal Figure 1. A model for 'Occupational Aspirations' from Gottfredson, 1981, Circumscription and compromise: a developmental theory of occupational aspirations. Journal of Counselling Psychology. 28(61. 545-578. A challenge to vocational psychology. 4 This model identifies factors which influence occupational aspirations and provides a way of identifying and understanding the issues involved in career choice. It presents occupational aspiration, in the context of perceptions (both personal and motivational) inherent in the particular occupation under consideration. As well, the model demonstrates a broad base from which the field of choice narrows, leading to the subsequent occupational aspiration. Personal factors such as self-concept, gender and interests as well as motivating factors such as perceived prestige (including financial gain) influence the range of acceptable occupational alternatives worth considering. This process of career choice is an ongoing process experienced by individuals from preschool through post secondary education. The key components of this model are described in the following sections. Self Concept Self concept refers to one's view of one's self — who one is and who one is not. It represents the totality of seeing one's self. Incorporated in self concept are factors such as one's view of one's abilities, social self, personality, and personal interests. Self concept may or may not coincide with an outsider's assessment of that person's personality. Occupational Image An occupational image is a generalization an individual makes about a particular occupation, Gottfredson (1981) believes occupational image to be a synonymous term to occupational stereotype. She prefers the use of the term occupational image to occupational stereotype as the latter has a negative connotation. Occupational Preference According to Gottfredson (1981) occupational preferences stem from individuals assessment of the compatibility between occupations being considered, their perceptions of self (who they would like to be) and the effort 5 they are willing to exert to attain their goal. "Those perceptions that are highly compatible with one's sense of self will be highly valued; those that are highly incompatible will be strongly disliked" (Gottfredson, 1981, p. 548). Perceived Accessibility of an Occupation Individuals may choose an occupation compatible with their self concept yet, a number of obstacles may make that occupation inaccessible to them. Accessibility accounts for obstacles or opportunities within one's social or economic environment which influence the likelihood of entering a particular occupation. The judgment the individual makes concerning these variables (obstacles, opportunities) influences how seriously the person will consider the occupation to be a viable career possibility. Occupational Alternatives Alternatives are preferences derived from perceptions of job self compatibility and accessibility. Interestingly, Gottfredson believes that if preferences are considered more than accessibility, the resulting occupational alternatives are idealistic, fantasy aspirations. However, if the reverse is true, the alternatives are realistic career plans. Social Space Social space refers to the range of occupations an individual considers acceptable. Some occupations may be more acceptable than others. This range is referred to as social space because it reflects the view not only of where the person fits in relationship to family and peers but, to society as a whole. Occupational Aspiration Occupational aspiration refers to the single occupation chosen as the individual's best possible alternative. Importantly, as perceptions of compatibility and accessibility change, so too can occupational aspiration even though one's social space remains stable. 6 Application of Theoretical Framework Gottfredson's theoretical model for occupational aspirations (1981) is appropriate for the study of high school seniors' perceptions of the nursing profession. The isolation of the critical components allows for their investigation and the role that they play in students' consideration of the feasibility of a nursing career. In this study, an attempt has been made to isolate some of the components inherent in self concept (for example, gender) as well as identifying students perceptions of nursing's prestige. Students are provided with the opportunity to compare their perceptions of their chosen occupation with nursing. These students are considered to be aware of the factors involved in job accessibility. Lastly, students are given the opportunity to identify those factors which influence the likelihood of nursing being considered as a possible career choice as well as what would have to change (if anything) to increase the profession's appeal. Research Questions There are several gaps in the existing research regarding the perceptions Canadian high school students have of the nursing profession. Therefore, this study attempted to answer the following specific questions: 1) What information do students have about registered nurses? 2) Where did students obtain information about registered nurses? 3) Where do students think registered nurses work? 4) What kinds of responsibilities do students think registered nurses have? 5) What education do students think registered nurses have? 6) In the opinion of these students, what would have to change (if anything) for the nursing profession to attract more young people? 7) What occupational image do these students have of nursing? 8) What occupational image do they have of their ideal career? 7 Significance for Nursing This exploratory study will help further the nursing profession's understanding of how one particular target group, grade twelve students, view nursing. Understanding high school students' perceptions of the nursing profession will assist the profession to plan suitable recruitment strategies aimed specifically at high school students. The ultimate aim of these recruitment strategies would be to encourage more young people to seek out nursing careers, thus helping to ensure a steady supply of nurses. Secondly, this study may help the nursing profession plan effective advertisement campaigns designed to further the general public's understanding of the nursing profession. It is anticipated that the image of nursing could be enhanced through this effort. Definition of Terms The following operational definitions were used in this study. Students: are those individuals in one of the two grade twelve classes attending the Vancouver Island high school used by the researcher for this study. Nurse: refers to an individual who has pursued a course of studies leading to qualifications which allow for registration by the Registered Nurses Association of British Columbia ( R N A B C ) . Nursing: refers to those responsibilities generally practised by registered nurses. Perceptions: refers to the understanding of and feelings about a particular situation or a particular issue. Perceptions are strongly influenced by an individual's developmental level and by an individual's self concept (Gottfredson, 1981). 8 Assumptions and Limitations The researcher assumes that grade twelve students are concerned about career choices. How these students view themselves at the concluding phase of their secondary education will have an influence on how they perceive of themselves in the future when a working adult. When grade twelve students are given an opportunity to complete a questionnaire designed to understand their perceptions of a particular career it is assumed that they will answer honestly and to the best of their ability. The results of this study are limited in their generalizability. A convenience sample was used and may not be representative of grade twelve students in general. This high school population may share particular characteristics which may have had an influence on how students responded to the questionnaire. As well, this study is limited by the extent to which students answered the questions honestly and thoroughly. Overview of the Thesis This thesis is comprised of five chapters. Chapter one includes the background to the research problem, the description of the conceptual framework and an outline of the study's purpose. Chapter two reviews selected literature on nursing image. Chapter three describes the research methodology including the use of the data collection tool, data collection procedure and data analysis. Incorporated in chapter four are the results of data analysis as well as a discussion of the study's findings. In the final chapter, a summary of the study, the conclusion, and the implications for both nursing practice and future research are presented. 9 C H A P T E R T W O L I T E R A T U R E R E V I E W Literature was reviewed in four areas: the concept of image as it relates to the theoretical framework occupational aspirations, the historical image of . nursing as perceived by the media, the implications of nursing's negative image and lastly, the image of nursing as documented in recent research. The Concept of Image Theories on vocational choice consider a number of factors which influence the process of choosing a particular occupation. These factors include, personality types, gender and socioeconomic background. However, Gottfredson, a vocational psychologist, has determined that factors such as these have failed to adequately address the issue of vocational choice. Through extensive research studies she has isolated the concept of image as an integral component of the process of career choice. Gottfredson (1981) believes image to be a fundamental ingredient in the development of self concept. The following discussion of image will demonstrate the linkages between self image and occupational image, as well as demonstrating how the process of career choice is made. Gottfredson defines image as the mental impression or picture created by exposure to and interpretation of particular events. By a logical, deductive reasoning process, these events are internalized, and interpreted. Conclusions are made based upon a number of factors such as culture and personal experiences. A n occupational image is a conclusion a person makes about a particular 10 occupation. Gottfredson (1981) views the term occupational image as corresponding to or being synonymous with occupational stereotype, a term denoting preconceived ideas about that particular occupation (p. 5-7). Occupational image may include generalizations about particular aspects of the job, such as entry requirements, work related responsibilities, rewards and conditions of employment as well as job status. According to Gottfredson, individuals assess the compatibility of particular occupations with their view of both who they are and who they would like to be. This she refers to as individual self concept, "the totality of different ways of seeing one's-self. Gottfredson's theoretical framework on occupational aspiration demonstrates the linkage between self concept and occupational preference. The image that individuals have of themselves greatly influences the image these individuals have of themselves in the work environment. If these are compatible, there is a strong likelihood of individuals considering that particular occupation. If these images are incompatible, there is a strong likelihood the occupation will not be considered. This overview of Gottfredson's concept of image and its relationship to the broader concept of career choice provides some insight into some of the issues surrounding recruitment. A review of the image of nursing as it is presented in the media will further the understanding of the recruitment issue as it relates to the nursing profession. Nursing Image as Presented by the Media Image of nursing is a term used to define "the sum of beliefs, ideas and impressions that people have of nurses and nursing" (Kalisch & Kalisch, 1988, p. 2). MacPhail (1988) believes that the image of nursing has become the 11 center of attention for the nursing profession. Nurse educators, researchers and nurses themselves are concerned that the current image of nursing as perceived both inside and outside of the profession is a negative one (Baumgart, 1988; Kalisch & Kalisch, 1988; Kerr, 1988). As nursing faces the future, a clear understanding of nursing's image will help to promote suitable recruitment strategies to increase its membership. A n understanding of the history of the image of nursing will help foster an understanding of the dilemmas facing the profession as it attempts to ensure its image is a positive one. The following is a brief overview of the changing image of the nursing profession. A n Historical View of the Image of Nursing Public opinion polls show that most of the new orientations and beliefs that adults acquire during their lifetime are based on information supplied by the mass media (Kalisch & Kalisch, 1987). Kalisch and Kalisch researched mass media products which included "the print media (200 novels, 143 magazines, short stories, poems and articles and 20,000 newspaper clippings), as well as the newer non-print media (204 motion pictures, 122 radio programs, and 320 television episodes) (1982, p. 5). Their extensive survey resulted in a classification of nursing image into five dominant historical types. Kalisch and Kalisch defined the first type as the "Angel of Mercy", occurring in the mid-nineteenth century. This was the Victorian era. Hospitals, and health care was unorganized and supported mainly by charitable donations. "Hospital funds were always short, rooms overcrowded, and the environment unsanitary. In the absence of special operating and treatment rooms and anaesthesia, the screams of the patients echoed throughout the wards. Under such conditions, alcohol, then a major hospital remedy, was perhaps the most humane prescription" (Kalisch & Kalisch, 1987, p. 12). Nurses were of the lowest socio-economic class, uneducated, past criminals and or prostitutes. Victorian "ladies" did not seek employment outside of the home. They were educated (prepared) for marriage and motherhood with the womanly arts of nurturing and entertaining stressed. Victorian woman was deemed too fragile to concern herself with the outside world, too weak to enter public life, to vote or to attain an outside education. It is therefore surprising that out of such a constrained environment one of nursing's foremost leaders emerged, Florence Nightingale. Nightingale was a prolific writer and was instrumental in developing a standardized educational program to train nurses (Summers, 1984) . Nightingale succeeded in raising nursing "from a loathsome, ill-regulated occupation to a respected profession composed of educated women specifically qualified to practice nursing" (Kalisch & Kalisch, 1987, p. 16). MacPhail (1988) describes Nightingale's achievements as "astounding". She was active during the Crimean war almost single handedly arranging for nurses to care for the sick and wounded soldiers at the battlefront. Nightingale was active in health and hospital planning and wrote a number of handbooks discussing the needs and care of patients. MacPhail suggests that had Nightingale's nursing model been followed more closely, the nursing profession would be in a more powerful position than it is today (1987, p. 49). Nightingale epitomized the ideal Victorian nurse — altruistic, unselfish, merciful and tender. She became a subject for writers and artists (hence the advent of the term "Lady with the Lamp") ministering faithfully to the ill with no thought of herself (Pittman, 1985) . The second image resulting from the work of Kalisch and Kalisch was termed the "Girl Friday" (1920-1930). Following World War I, women had succeeded in casting aside the confines of house and home and were pursuing new areas of personal growth. "More and more women including wives and mothers were demonstrating their capacity to hold jobs outside their homes above the level of domestic servant or file clerk" (Kalisch & Kalisch, 1987, p. 57). Traditional female values of Victorian days were abandoned with delight as women rejected their cloistered existence and enjoyed their postwar freedom. As discussed by Kalisch and Kalisch, even the fashions changed dramatically with the advent of the "flapper" era. However, the dominant public image of the 1920's media nurse was less than favorable. Nurses were portrayed as handmaidens, subservient to physicians and, incapable of making any independent decisions. They were shown to place more emphasis on love and romance than on caring for patients. Frequently the source of their affections were the patients themselves, or other males within the hospital setting. Nurses in novels frequently went beyond traditional sexual morality (Kalisch & Kalisch, 1987). The nursing profession was deprofessionalized as standards within schools of nursing declined due to poor working conditions and exploitation of students (MacPhail, 1987, p. 49). Kalisch and Kalisch identified the third image of nursing as the "Heroine" from the 1930's-1940's. Despite the downturn in the American economy (the Great Depression) the public image of nursing was relegated to an all time high. Nurses were depicted as brave, rational, dedicated, decisive, humanistic, autonomous professionals. During this era the motion picture industry made great technical strides especially with the advent of sound. Movies depicted nurses in strong roles. Nursing appeared as a worthy, important profession that enabled women to earn a respectable living (Kalisch & Kalisch, 1987, p. 81). Nurses were viewed as heroines in war films, dramas, crime and detective movies. One motion picture, "The White Parade" (20th Century Fox, 1934), was entirely focused on nursing and was nominated for "Best Picture" by the 14 Academy of Motion Picture Arts and Sciences (Kalisch & Kalisch, 1987, p. 83). There was an added focus on military nursing with nurses taking an active role in the "war effort". "Patients' welfare always outweighs the nurses' own fears; pragmatism and flexibility mark their work. The nurses set up hospitals in the jungle and provide nursing care despite the lack of supplies and medicines" (Kalisch & Kalisch, 1987, p. 109). The image of the nursing profession as portrayed by the media through the years 1945-1956 was termed "Wife and Mother" (Kalisch & Kalisch, 1987). Surprisingly, women in large numbers eagerly returned to their more traditional roles of nurturer leaving, careers and independent lifestyles. "In the two years following the termination of hostilities (ie. World War II), the number of females in the labour force declined by about two million" (Kalisch & Kalisch, 1987, p. 126). Women married young, had large families and devoted their energies to maintaining house and home. Women's magazines, powerful sources of advertising, exalted female virtues. Women were instructed to undertake "traditional homemaking tasks such as cooking and decorating", they were discouraged in pursuing more "manly" activities in fields such as " law, mathematics, physics, business, industry and technology" (Cohen, 1988, p. 85). Women in increasing numbers fulfilled their "biological roles" and maintained house and home (Shockley, 1975; Summers, 1984). North American populations grew dramatically (hence the advent of the term "baby boomers") (McDaniel, 1986). Those women who were employed outside of the home, worked in occupations in which they were the dominant sex. Sexual division within the whole labour force was clearly evident. Professional women fell into two categories, nurses or teachers (Cohen, 1988). Ironically, both of these professions were viewed prestigiously. However, despite this prestigious view, 15 nursing was the lowest paid when compared to other professions of comparable education and experience. Women in movies during this era were depicted as "husband- hunting girls". Work was relevant only in that it provided the opportunity for women to seek romance, with marriage and family the ultimate end goal. Nurses depicted in movies of the late 1940s and 1950s were featured in roles of romance seeking "marital and domestic fulfilment" (Kalisch & Kalisch, p. 136). Nursing careers were terminated once these goals were met. Nurses who were represented in the media personified the ideal American woman ~ "optimistic, cheerful, talented, healthy, athletic, naive and pretty" (Kalisch & Kalisch, 1987, p. 141). The publishing industry contributed to nursing's image as well. There was a proliferation of romance novels during this time period. "800 romantic novels about nurses were churned out as if from an assembly line" (Kalisch & Kalisch, 1987, p. 142). Once again, the underlying themes perpetuated societal values of women in domestic roles. Nurses were depicted as nurturing, maternalistic and altruistic women. In novels and in movies it was imperative that the nurse become romantically involved with a dominant male character. Marriage was always the end result. The weaker character, the nurse, needed to be protected, loved and materially supported. According to Kalisch and Kalisch the image of nurse as devoted wife and mother plummeted dramatically in the mid 60s. Not since pre-Nightingale days did such a negative image of nursing emerge. The dominant perception of nurse during the 60s was that of "Sex Object". Despite the advent of the feminist movement, North American advertisements (predominantly television and magazines) characterized women as sex object consumers (Summers, 1984). This had a rebound effect on the nursing profession. Television and movie industries preoccupied themselves 16 with nurses' sex lives. This left little time to explore professional aspects of the nursing profession and left a somewhat tainted view of the profession itself (Kalisch & Kalisch, 1987). Who among us could ever forget Margaret "Hot Lips" Houlihan from the ever popular television series M*A*S*H*? "The presentation of nurses as sexually provocative - tight uniforms and elaborate make-up - was a recurring theme in many films, novel and television shows of the 1970s" (Kalisch & Kalisch, 1987, p. 163). Even "X rated" films used the nursing theme for main female "characters". "Of all restricted and 'X rated' films with occupationally linked titles released from 1966-1984, nurse in some form was used in 21% of the titles" (Kalisch & Kalisch, 1987, p. 166). The more contemporary ideal view of the nurse Kalisch and Kalisch refer to as the "Careerist". It is the view of these authors that it will take a great deal of work to combat the all time low image of the nursing profession to attain this ideal. There is a pervasive belief among society that nursing is an outdated profession (Ryten, 1988). "Entrance into the profession is too often regarded as one more surrender to the narrowing of personal ambition and is an unadventurous acceptance of the strictures of gender-role specialization" (Kalisch & Kalisch, 1987, p. 185). In order to ensure that the nursing profession is able to attract its share of the pool of available young people it is essential that nursing portray a strong image. The implications of nursing's negative image as shown by Kalisch, Kalisch and others (Day, 1987; Kerr & MacPhail, 1988; Moloney, 1986; Ryten, 1988) will now be addressed. Implications of the Negative Image of Nursing The average American high school graduate has spent more time watching television than attending school (15,000 hours versus 12,000 hours) (Kalisch & 17 Kalisch, 1987, p. 187). Television has a strong impact on its vulnerable audience. Individual viewpoints become moulded by the mass media. Negative viewpoints have been shown to translate into actual behaviours (Kalisch & Kalisch, 1987, p. 180). Similarly, Gottfredson (1981) has demonstrated that attitudes which have developed from the mass media will transpose themselves into attitudes individuals have towards occupational choice. Individuals who view negative images of nurses in the media may have a low opinion of the nursing profession. "Stereotypes are reinforced until they become unquestioned assumptions, and ultimately an integral part of the mass culture of the society" (Day, 1987, p. 30). Young people who are able to choose from a wide variety of possible careers will be reluctant to choose nursing. Those whose choice may be somewhat restricted may consider nursing. Thus the nursing profession may have a difficult time in ensuring its recruits are "quality" as the available pool of new members has been drastically reduced (Beauchamp, 1989). Secondly, the negative image of the nursing profession may have serious implications for individual nurses. Feelings of low self esteem related to the profession's negative image may directly contribute to stress related problems within the workplace. As a result, the nursing profession is experiencing a high attrition rate (Beauchamp, 1989). This discussion of nursing's image has clearly demonstrated the negative stereotypical view society in general has of the profession. Multiple forces within the concept of image are creating a major impact on enrolments within schools of nursing (Kerr, 1988). To further an understanding of the issue of nursing's negative image, it is helpful to explore how the profession is viewed by students. 18 Webster (1985) studied the role of the nurse as viewed by a group of medical students. "Less than 20% of third and fourth year medical students were aware of nurse's independent role" (p. 316). According to Webster nursing was seen as entirely dependent on the physician's instigation of care, as well as the physician's supervision of all levels of care. Medical students studied, did not see nursing as an autonomous profession with distinct roles and responsibilities. Webster's study clearly documented confusion over nursing's role within health care. Due to misinformation, and lack of information this study found that medical students identified nursing's function through personal biases and stereotypical images. Webster refers to nursing's "Cinderella Syndrome" wherein nurses take a background role especially when medical personnel are in view. These medical students consistently devalued contributions nurses make to patient care. Kersten, Bakewell and Meyer (1990) found that practising nurses were identified most frequently as influencing students' image of nursing, and thus their choice of pursuing a nursing career. The nursing profession is experiencing an image problem. Obviously, nurses who are feeling negative towards the nursing profession will be reluctant to speak favorably about the profession (Baumgart, 1988; Beauchamp, 1989). Thus nurses themselves contribute to the recruitment issue. Kersten, Bakewell and Meyer (1990) refer to nurses as the "mirror image" of the profession. Nurses who reflect a positive view of the nursing profession would help to encourage more young people to pursue nursing careers. Kohler and Edwards (1990) investigated the perceptions high school students have of nursing as a career choice. Their findings revealed that few students (8.6%) were considering nursing as a career option. Nursing education was seen as too costly, and too time consuming for the final rewards. 19 Nurses responsibilities were labelled "unpleasant" and working conditions for nurses was defined as "poor". Thirty percent of the subjects saw nursing as a low status occupation. This study identified key factors which have a negative impact on choosing nursing as a career. These included, the difficulty in obtaining a nursing education, the perception of poor monetary rewards, and the relatively poor status of the profession. Naylor and Sherman (1988) in their study "Effects of Current Initiatives to Attract Quality Undergraduate Nursing Students" documented not only a significant decrease in the number of individuals pursuing a career in nursing, but a decline in the quality of the nursing student applicant pool. Their study identified business as the number one major and career goal of studied students. Myths and stereotypes continue to perpetuate a negative image of the profession. According to Naylor and Sherman (1988), nursing is seen as offering too little money, having poor status, and possessing limited power --factors which make students reluctant to consider entering the profession. Summary of Literature Review The literature reviewed illustrates some of the problems surrounding the issue of recruitment into the nursing profession. A definition of occupational image as viewed by the vocational psychologist, Gottfredson (1981) was presented. There is strong evidence that the correlation between self image and occupational image influences the extent to which individuals choose careers. A review of the work of Kalisch and Kalisch (1987) demonstrates how the media's view of the nursing profession has changed through history. Society's current view of the nursing profession is less than favorable. Nursing is perceived as an outdated profession offering limited career opportunities. 20 Throughout various forms of media a negative stereotypical vision of the nursing profession prevails. The implications of nursing's negative image were discussed. Because the issue of recruitment of young people into the nursing profession was seen as being related to perceptions of nursing, a review of recent literature pertaining to this topic was discussed. A l l of the studies examined indicated that an image problem existed. There was a prevailing belief among the students that nursing lacked professional autonomy. Nurses were poorly paid and worked under poor conditions. Generally, students were not interested in pursuing nursing careers as other forms of occupations were perceived as providing opportunities for generating intrinsic and extrinsic rewards. In summary, the nursing profession has an image problem. Since there is clear evidence that declining enrollments into nursing programs exist, and as young people are a source of new recruits, research addressing the issue of recruitment of young people into nursing is timely. This study was undertaken with the purpose of furthering an understanding of the complex issue of nursing recruitment. 21 C H A P T E R T H R E E M E T H O D S In this chapter a description of the study design and sample are presented. Also included in this chapter are the human rights and ethical considerations, the data collection procedure, data collection instrument and the process of data analysis. Design A descriptive correlational design guided this study. This is appropriate as the researcher anticipated a relationship existed between feelings students have towards their chosen occupation and feelings they have towards the nursing profession. A descriptive correlational design facilitates an initial description of the variables, as well as providing a means for determining if relationships exist between the perceptions students have of nursing, and the present realities of the nursing profession (Rudov, Wilson & Trocki, 1976). Sample The sample consisted of thirty-six grade twelve students attending a high school on the east coast of Vancouver Island. Students were selected solely on the basis of their student timetables. The researcher desired to have the students in one geographical location for ease and accuracy of questionnaire distribution. Participants were obtained in accordance with the following criteria: 1. Students were in grade twelve, attending the local high school class. 2. Students did not suffer from a physical or mental disability which would 22 make them unable to answer the questionnaire. A l l students were English speaking. 3. Each involved grade twelve student was in one particular class. A l l students in the class chose to participate. No questionnaire was returned unanswered. Human Rights and Ethical Considerations This study was approved by the University of British Columbia Behavioral Sciences Screening Committee for Research and Other Studies Involving Human Subjects. Prior permission to conduct this study had been obtained from the administration of the high school attended by the students. Students received an information letter "Introduction to the Study High School Seniors' Perceptions of Nursing" (appendix A ) . This letter clearly informed the students of their right to refuse to participate in the study. The morning of the study the researcher met with the class, confirming students had received the letter of introduction, understood confidentiality, as well as their right to refuse to participate in the study (students were requested to hand the questionnaires (appendix B) back blank if they did not want to participate in the study). Students consented to participate in the study by completing the questionnaires. As the majority of the students were seventeen and older, were graduating high school students and were competent to understand the nature of their participation, the principal of the high school felt that no other permission or consent forms were required. This was approved by the University of British Columbia Behavioral Sciences Screening Committee for Research and Other Studies Involving Human Subjects. A l l respondents to the study remained anonymous. A l l replies were confidential. No one had access to the collected data except for the researcher 23 and members of her thesis committee. A l l results were first analyzed individually and then presented as a group. There is no way to identify individual participants. Data Collection Procedures Data were collected through a hand delivered questionnaire. The researcher met with the class involved to ascertain that students had received their information letter and clearly understood the nature of their participation. Each student in turn was handed a questionnaire. The researcher circulated through the class to answer any questions as they arose. As students completed their questionnaires they placed them face down on their desks and the researcher collected them. Most of the questionnaires were completed within fifteen minutes. Two students took twenty minutes to complete the questionnaire. The process, from introduction to completion took twenty-five minutes of class time. Data Collection Instrument At the time the researcher was developing the questionnaire, the only instrument found in the literature was a tool designed by Rudov, Wilson, and Trocki (1976), "High School Seniors' Attitudes and Concepts of Nursing as a Profession". Permission to use the tool and make changes as deemed necessary was obtained from the U.S. Department of Health and Human Services (formerly Health, Education and Welfare). This instrument investigated the following areas related to the nursing profession: job desirability, nursing school admission requirements, starting salary of occupations, nursing tasks, and finally, academic preparation for nursing school admission. A general background section was included to assist in analysis and interpretation of the data. As the focus of this study was on students' perception of nursing some 24 changes were made to the existing questionnaire. The section on demographics was reduced to include only the key variables of gender, age, career decision (desired occupation) and where information about nursing was obtained. Guided by Gottfredson's theoretical framework, the instrument was divided into three sections: knowledge of nursing (to identify the level of information students have of the roles and responsibilities of nurses within communities), occupational image (to determine what students think about nursing), and finally, occupational preference (the image students have of themselves in a particular occupation). The relationship between occupational image and occupational preference was the main focus of this study. Content validity of the questionnaire was pilot tested using a group of senior high school students. The language of the questionnaire was simplified and the questionnaire shortened to remove extraneous material. Following these changes the questionnaire was again tested and no difficulties were encountered. None of the students who were pilot tested were included in the final study. Data Analysis Data was analyzed using frequency and distribution statistics. As the survey responses are more qualitative than quantitative, and due to the small sample size this was seen as the preferable method. The prime intent of this study was to identify areas of consensus among grade twelve students rather than to seek out statistically significant differences in group responses. 25 In summary, this chapter has presented the design for the study "High School Seniors' Perceptions of Nursing". The sample characteristics were given. A review of the procedures to fulfil ethical and human rights responsibilities was documented as well as the nature of data collection procedure, data collection instrument and the process of data analysis. CHAPTER FOUR PRESENTATION AND DISCUSSION OF FINDINGS This chapter is divided into three sections. The first section reports the sample characteristics. The findings related to the research questions are presented in the second section. In section three a discussion of the findings is presented. Sample Characteristics Thirty-seven students responded to the questionnaire. One questionnaire was returned missing substantial data, and was excluded from the study. Guided by the theoretical framework (Gottfredson, 1981) the researcher isolated the component of gender. Gottfredson has defined gender as being integral to the development of self image, and eventual occupational aspiration. The majority of respondents were female (58%) between sixteen and nineteen years of age. All were grade twelve students planning on graduating in the spring of 1991. All respondents indicated a desire to pursue post secondary education. Of the surveyed students, 38% of the females and 53% of the males indicated that they had made "firm" career plans. Findings Related to Research Questions Findings related to question one and two reveal the respondent's exposure to nursing. Results pertaining to research question three, communicates students' understanding of where nurses work. Data obtained on research question four covers the responsibilities of nurses, as viewed by surveyed students. In question five, students are asked what education they believe nurses require. Findings from research question six, reveals what students 27 believe needs to be changed for the nursing profession to attract an increased number of young people. In research question seven, students identify nursing's occupational image. Lastly, in research question eight, students share their vision of occupational preference. Research Question 1 & 2: Respondents Exposure to Nursing As reflected in Table 1, "relatives who are nurses' was the most common exposure to the nursing profession cited by both male (60%), and female (62%) students. 25% of all students indicated exposure to nurses as patients. 50% of all students surveyed indicated the media as providing them with information about nursing. Table I: Information About Nursing SOURCE M A L E F E M A L E Relative 60% 62% School Counsellor 0% 19% Personal Exposure 20% 5% Television 33% 57% Other Media 27% 24% * Note: It is possible that a respondent could be represented in more that one category. The use of the counselling service for information on other careers and post secondary institutions occurred with both males and females in varying amounts (Table II). 28 Table II: Use of the Counselling Service FREQUENCY MALE FEMALE A Couple of Times 40% 48% More Than a Few Times 27% 29% Once 20% 19% Not at All 13% 4% Research Question 3: Where Nurses Work Data regarding respondents knowledge of nurses working areas are presented in Table III. Only ten students (representing 28%) of the students surveyed were able to correctly identify all of the listed areas as employing nurses. Table III: Work Areas of Nurses WORK AREAS (F) MALE (F) FEMALE Armed Forces 7% 10% Community Health Agencies 7% 5% Alcohol and Drug Abuse Centers 7% 52% Industry and Business 20% 43% Private Practice 7% 43% Hospitals 100% 100% Educational Institutions 0% 43% Doctor's Offices 0% 14% Outpost Centers 0% 14% Emergency Centers 7% 0% Mental Health Agencies 7% 48% Prisons 7% 33% Health and Welfare Organizations 7% 33% * Note: (F) stands for the frequency of responses. 29 Research Question 4: Responsibilities of Nurses Data pertaining to respondents knowledge of nursing responsibilities are presented in Table IV. Generally, students were unclear about the nurse's role. They were unaware of the vast career opportunities found within the nursing profession, as well as the scope of nursing practice. Table IV: Nursing Responsibilities JOB ACTIVITIES (F)MALE ( F ) F E M A L E Administers Other Health Care Personnel 20% 38% Handles Sophisticated Monitoring Equipment 14% 14% Teaches Pregnancy Classes 40% 57% Performs Physical Exams 0% 43% Delivers Babies in Remote Communities 21% 24% Performs Secretarial Work for Doctors 0% 38% Delivers Nursing Care to Clients in Their Homes 7% 29% Teaches at University 53% 43% Educates the Public 33% 29% Nurses in Private Practice 33% 19% Provides Emergency Care 0% 10% Counsels Employees 14% 16% Provides Screening Programs 33% 24% Counsels Clients in Alcohol and Drug Abuse Centers 60% 57% Acts as Consultants for Business and Community 14% 18% Establishes Safety Programs 47% 52% Teaches Patients 33% 24% Screens Children for Vision and Hearing Problems 33% 24% Prepares and Manages Health Care Budgets 7% 20% Provides Twenty-four Hour Health Care within Hospitals 7% 20% Conducts Research on Various Aspects of Health Care 40% 52% Functions as Infection Control Officers 20% 33% Directs and Manages Nursing Services 20% 24% Serves on Hospital Ethics Committees 20% 19% Counsels Mentally 111 Clients in Their Homes 47% 57% Research Question 5: Education of Nurses 30 Students were asked to identify the educational preparation of nurses. The data are presented in Table V. University education was the most common response, indicated by 69% of students surveyed. Table V: Education of Nurses Research Question 6: Changes to Nursing The data obtained from this question are presented in Table VI, VII and VIII. First, students were asked if they would consider nursing as a career. Three females and one male responded affirmatively. Secondly, students were asked to clarify their responses by indicating possible reasons for their decision. These have been categorized for ease of interpretation. S O U R C E (F)MALE (F) F E M A L E University 80% Medical School 20% Nursing School 0% Fligh School and First Aid Courses 0% Don't Know 0% No Reply 0% 62% 10% 5% 15% 3% 5% Table VI : Reasons for Not Considering Nursing REASONS (F)MALE (F) F E M A L E Low Pay 27% 30% Too Much Stress 13% 10% Too Depressing 7% 10% Too Much Education 19% 25% Poor Hours 0% 15% Table VII: Reasons for Considering Nursing REASONS Like a Fast Pace Like Helping People Would Consider it if Nothing Else to do (F)MALE (F) F E M A L E 7% 0% 15% 7% 0% Table VIII: Changes to Nursing C H A N G E (F)MALE (F) F E M A L E Nothing Can Help 13% 43% Change Image of Nurses Fighting 7% 10% Advertise the Positive 27% 14% Educate the Public About Nursing 7% 10% Improve Benefits and Wages 60% 29% Improve Equality With Medical Profession 70% 5% 32 Research Question 7: Occupational Image 87% of the males, and 67% of the females surveyed identified the nursing profession as being on the "mid to low end" of the pay scale. 100% of the students felt the nursing profession would be personally rewarding, as well as professionally challenging. Female students felt nursing to be a "mid to high status" occupation. However the males differed considerably, with 40% of them identifying nursing as "low status". Students in general viewed nursing as a challenging profession, offering opportunities for career advancement. However, nursing required "hard" work, and working hours were seen as "poor". Female students saw the nursing profession as having opportunities for self supervision while males saw limited opportunities for self supervision. Research Question 8: Occupational Preference Not surprisingly, 100% of the surveyed students indicated they were looking for careers that will pay well. As well, their chosen careers will be personally rewarding, have high status, be challenging and offer opportunities for career advancement. Their chosen careers will also have good working hours and offer the opportunity for self supervision. Students did not identify their chosen occupation as being gender restricted. Discussion of Findings Findings will be discussed under the following three headings: knowledge of nursing, occupational image, and occupational preference. 33 Knowledge of Nursing Similarities were found between this investigator's findings and those of other researchers studying students' perceptions of nursing. Students indicated they had received information about nursing from two main sources (personal acquaintances and the media). The study done by Marriner-Tomey, Schwier, Maricke, and Austin (1990) determined that 63% of students indicated information about nursing had come from nurses they knew as friends or relatives. This compares favorably with the results of this study (60% of males and 62% of females) indicated information about nursing had come from relatives. In addition, this study confirmed the importance of the media in relaying information about nursing. However, the negative implications of information obtained from these two main sources can not be ignored. Image of Nursing Complaints from nurses in the work setting center around a number of issues. These include lack of professional autonomy, low salaries, and low prestige (Norby, 1987). Research has shown that the negative attitudes nurses have towards the profession will influence behaviour. Nurses will generate negative comments to students seeking information on the profession (Kalisch & Kalisch, 1987). It has been well documented that the media, in combination with other factors, present a negative image of the nursing profession (Kalisch & Kalisch, 1987). The theoretical framework for this study links individual aspirations (the eventual choice of career) with a positive self concept. The prevalence of negative attitudes toward a particular career will do little to enhance individual self concept. It would be unlikely for an occupation perceived of negatively to be considered as a career alternative. Conversely, a profession generating 34 positive comments will enhance feelings of self esteem and will be considered as a career possibility, providing career accessibility is seen as likely (Gottfredson, 1981). Few (N=4) students were able to correctly identify areas of nursing employment beyond the traditional hospital setting. Fewer (N=2) students could correctly identify nursing areas of responsibilities. It is clear that students were unaware of the career possibilities found within the nursing profession. Data revealed that students were aware of the educational requirements needed to become a nurse. This literature gives some indication that students consider the extent of nursing education to be too costly in terms of time and effort (elements of occupational aspiration) for the end result (Marriner-Tomey, Schwier, Maricke & Austin, 1981). As seen by the theoretical framework (Gottfredson, 1981), accessibility can be a determining factor in career choice. Data from this study found that feelings of being useful would be important considerations for choosing a nursing career. This confirms the work of Kersten, Bakewell, and Meyer (1991) and Marriner-Tomey, Schwier, Maricke, and Austin (1990). Occupational Preference The final portion of the survey identified students' occupational image of nursing and their occupational preference (ideal career). Some differences between the genders were encountered. Males perceived of nursing as lower in status than did the females. However, both sexes identified the desire for a prestigious career. Given the relatively poor image of nursing as identified by Kalisch and Kalisch (1987), perceptions of low prestige discourage students from considering a nursing career (Kersten, Bakewell & Meyer, 1991). Perceptions of poor working conditions inherent in the profession would 35 discourage students from considering a nursing career. Both sexes identified the desire for their chosen career to have good working conditions. Males indicated their chosen careers would necessitate "hard work", while the females surveyed were neutral. Whether or not a nursing career would mean "hard work" does not seem to be an issue for these students. Opportunities for career advancement and the chance for self supervision correlated positively between occupational image and occupational preference. There was slight difference differences between the sexes. Males identified nursing as providing "little opportunities for self supervision". In summary, students who were surveyed lacked information about nursing. They were unaware of the variety of employment opportunities found within the health care system, community and government agencies, industry, as well as the possibility of private practice. Students had unclear ideas of what nurses do. The image of nursing held by the students is a negative one. It is not surprising, therefore, to find few students interested in pursuing a nursing career. 36 C H A P T E R F I V E S U M M A R Y . C O N C L U S I O N S . IMPLICATIONS A N D  R E C O M M E N D A T I O N S This study was designed to describe the perceptions of a group of grade twelve students regarding the nursing profession. Using a questionnaire designed by the researcher, students identified perceptions of nursing as well as their own occupational preferences. The questionnaire was divided into three sections. In section one, students identified those areas and job related responsibilities they felt were within the profession's domain. In section two, students' occupational image of nursing was identified. The final section identified students' occupational preference. A n overview of the study is presented in this chapter followed by conclusions. Lastly, implications for nursing in general, nursing education and nursing research are discussed. Summary This study was based upon the premise that high school seniors are concerned about careers, and are making career choices based upon a number of factors: gender, social class, intelligence, interests and values. Gottfredson's (1981) theoretical framework identified these factors as comprising individual self concept. Self concept was seen to be a key component in occupational aspiration, leading to occupational image, and culminating in occupational preference. Occupational aspiration is the end result. The image individuals have of themselves is directly correlated to the image individuals will have of 37 themselves in an occupation under consideration as a career possibility (Gottfredson, 1981). The literature reviewed indicated that the image of nursing is poor. Not surprisingly, perceptions of low wages, poor working conditions, and low prestige (Layton, 1988) were seen as directly contributing to declining enrollments in nursing programs. As well, these negative factors have been implicated in discussions of the high turnover rate within the nursing profession. According to Kohler and Edwards (1990), when faced with unlimited career possibilities, young people in general are uninterested in nursing careers. Personal investments of time and money to obtain a nursing education are considered too great. The traditional view of the nursing profession as defined by Kalisch and Kalisch (1987) is greatly influenced by the media. Negative stereotypical views of nurses as handmaidens directly contribute to the general negative image of the profession. Quite possibly nurses themselves are an underestimated force contributing to nursing's negative image. In this study, 61% of the students surveyed indicated that personally knowing nurses directly contributed to their knowledge of the profession. This finding was consistent with the literature in defining nurses as a major force in providing information about the profession (Marriner-Tomey, Schwier, Maricke & Austin, 1990). Negative attitudes nurses have of their profession are thought to directly influence enrollment patterns in nursing programs (Baumgart, 1988; Beauchamp, 1989; Ryten, 1987). The concept of image was presented in the literature as a major influence on students career choice. Gottfredson's framework further supports this by asserting that a positive correlation exists between self image and occupational aspiration (Gottfredson, 1981). Students with positive self images are more 38 likely to pursue an occupation that reflects (and/or reinforces) this positive view. Occupations which are perceived of as contributing to a negative professional image will be rejected as career possibilities. This descriptive study was conducted using a group of students from a rural community on the east coast of Vancouver Island. The final sample comprised thirty-six grade twelve students. Each of the respondents completed the questionnaire 'High School Students' Perceptions of the Nursing Profession'. Data were analyzed using frequency, descriptive statistics. Results indicated that students' perceptions of the nursing profession were negative and outdated. In general, students were reluctant to consider a career in nursing. Similar results were found by Kohler and Edwards (1990) and Marriner-Tomey, Schwier, Maricke, and Austin, (1990). A particularly disturbing finding revealed that, among the female students surveyed, responses were more negative than were those from malesvas in the sample. This may be of concern to the nursing profession, considering that the vast number of nurses are women. A small percentage of the males surveyed held steadfast to the stereotypical vision of nursing as being "just for women" (Ryten, 1988). The results of this study have furthered the understanding of why students are reluctant to consider a nursing career. The students surveyed desired a career perceived of as "personally satisfying". Chosen careers, according to the respondents to the questionnaire, must also offer the opportunity for career advancement and independence. As well, the vast majority of students stated that satisfactory financial remuneration was a big consideration when choosing careers. 39 The "traditional" view of the nursing profession (Kalisch & Kalisch, 1987) does not fit with these students' idealized vision of a career. This study documented that students were not aware of the opportunities found within the nursing profession. They had only a limited knowledge of settings where nurses work and of activities performed by nurses. Only three students could correctly identify all the work areas where nurses were employed. What is also significant is that the "nontraditional" job activities such as counselling and consulting were almost universally not seen as to fall within the scope of nursing practice. It is interesting to note that when asked what would have to change to entice more young people to consider a nursing career, the response "increase wages and benefits " was indicated by seventeen respondents. It is apparent that these students hold a traditional view of nursing as being "self sacrificing" (Kalisch & Kalisch, 1987) and thus underpaid, yet, the starting wage for a beginning Registered Nurses here in British Columbia is $18.26 an hour (British Columbia Nurses' Union, 1990). The theoretical framework "Occupational Aspirations" (Gottfredson, 1981) guided the interpretation of study results. It was postulated that students' perceptions of nursing would be based on outdated ideas of the profession. This study confirmed that students' general knowledge of the nursing profession was limited as well as inaccurate. Students were unaware of the scope of nursing practice. Further, this study identified key factors (including the perception of poor wages and poor working conditions) as discouraging young people from pursuing nursing careers. The major findings of this study correlate with findings of studies conducted by Holtzclaw (1983), Kohler and Edwards (1990) and Marriner-Tomey, Schwier, Maricke and Austin (1990). i Conclusions The results of this study confirm that nursing continues to struggle with an image problem. However, this study should be interpreted with caution. The small sample size (N=36) may not be representative of grade twelve students as a whole. As well, the community studied may have particular attributes that set it apart from other communities, thus contributing to student responses. Interestingly, this particular community offers few career opportunities for new high school graduates. Within the community, there appears to be a prevailing attitude among young people that they will eventually leave the community to pursue careers. As this study indicated, all participants planned to further their post secondary education. This particular community does not offer any form of post secondary education aside from distance education programs. Implications for Nursing Practice According to this study, students have received information about the nursing profession primarily from nurses they know. It is possible to speculate that some of the negative attitudes that students have toward the nursing profession may have originated from this primary source. Nurses who feel good about themselves as professionals will willingly share their positive feelings about the profession, and will portray a positive image of the profession (Ryten, 1988). Somehow the message must get through to the "grass roots" that nurses are important and make a strong contribution to the health care system. The Registered Nurses Association of British Columbia as well as the British Columbia Nurses Union must make a continued effort at presenting a positive view of nursing. This can be accomplished through educational programs and advertising campaigns. Continued support of such programs as "media watch" will help to reduce and eventually stop negative stereotyping of 41 nurses. The lines of communication between the medical and nursing profession need to be improved so that the nursing profession can be viewed as an autonomous profession, which makes decisions, is self regulatory and a dominant force within health care (Baumgart, 1988). Continued efforts need to be made to present nursing as an "androgynous" profession (Holtzclaw, 1983). This will help to foster an attitude that nursing is not gender restricted. More males would be encouraged to consider a nursing career (Vas, 1987). Kalisch and Kalisch (1987) have pointed out that a mix of sexes would strengthen the profession. However, in keeping with this premise, the message must be made clear to women that a profession comprised of women can be strong and offer numerous personal rewards (Ryten, 1988). Implications for Nursing Education As was demonstrated through this study, the majority of students surveyed had clear ideas of what career path they were planning to pursue. Given this phenomenon, it would appear that advertising campaigns, conducted by post secondary institutions for the purpose of recruitment, should begin in earlier grades (prior to the time when students make career decisions). Implications for nursing education are clear from the conclusions of this study. First is the issue of image as it relates to students, prior to entering nursing programs and during their studies. A strong professional image directly relates to the numbers of individuals willing to pursue a career within that profession. Those professions which are perceived of prestigiously, have little difficulty in attracting a steady number of new recruits (Baumgart, 1988; Beal, 1988; Ryten, 1988). Nursing programs need to include courses on nursing image. The ultimate aim of such courses is to enhance the image of the profession as a dynamic contributing force within the whole health care system 42 (Beauchamp, 1989; Moloney, 1986). The focus on university education for nurses will assist in this process (Baumgart, 1988). The issue of image in the workplace needs to be addressed. Inservice education and other programs within the work setting need to offer the opportunity for nurses to learn what professional behaviours both detract from and enhance their professional image. Seminars and workshops would provide opportunities for practising nurses to work on their professional image thus presenting a strong professional image to the public. Thirdly, the declining pool of high school graduates (Holtzclaw, 1983) means that the nursing association needs to concentrate on a nontraditional market as a source of new recruits. More older adults are returning to post secondary education. Continued efforts need to made at reaching this potential market and expose them to the positive aspects of a nursing career. Recommendations for Research This study provides a foundation for further research on the image of nursing as seen by a variety of groups. These could include, younger populations, the general public, "mature students", and various ethnic minorities. Given the diversity of the Canadian population there is much to learn. When new strategies are implemented to enhance the image of the nursing profession, further research could assess the results of those efforts. Replicating this study with another group of individuals from another community would add to the body of knowledge on nursing image. This final chapter has provided a summary of the study "High School Seniors' Perceptions of the Nursing Profession". Conclusions were discussed and recommendations proposed. On the basis of this study the following 43 conclusions regarding grade twelve students' perceptions of nursing are made. Students have limited knowledge about the current status of the nursing profession. Lack of information and or misinformation perpetuates the stereotypical view of the nursing profession. Nursing is seen as lacking prestige. Students believe that nurses are paid poorly and work under poor conditions. 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Ryten, E . (1988,June). Women as deliverers of health care. Paper presented at the Conference of Canadian Association of University Schools of Nursing (1987). Shockley, J. Perspectives in femininity. Nursing Digest. 75(6), 49-52. Summers, A. (1984). Images of the nineteenth-century nurse. History  Today. 10. 16-18. Vas, D. (1986). High school senior boys' attitudes toward nursing as a career. Nursing Research. 17, 533-538. 48 A P P E N D I X A - S U B J E C T I N F O R M A T I O N L E T T E R 50 A P P E N D I X B - D A T A C O L L E C T I O N T O O L D A T A C O L L E C T I O N T O O L QUESTIONNAIRE: Background Information 1. You are: • Male d Female Age: years 2. Do you plan to continue your formal education after completing high school? • Yes • No 3. How many times during high school have you talked to your Counsellor about careers? Check the most appropriate box. • Not at all L*3 A couple of times • Once More than a few times 4. Have you made a firm decision about your future career? • Yes [ J N o 5. Do you personally know any Registered Nurses? • Yes • No 6. Where have you obtained information about the nursing profession (e.g. relatives, t.v., books)? Be as specific as you can. 52 K N O W L E D G E O F N U R S I N G 1. From the following list of work areas check (•) those areas that you think registered nurses would work in. Armed Forces [ ] Community health agencies [ ] Alcohol and drug abuse centers [ ] Industry and business [ ] Private practice [ ] Hospitals [ ] Schools and other educational institutions [ ] Doctors' offices [ ] Outpost health centers [ ] Emergency centers [ ] Mental health agencies [ ] Prisons [ • ] Health and welfare organizations [ ] (for example Heart Foundation) 2. From the following list of job activities check (•) those that you think are done by registered nurses. Administers other health care personnel [ ] handles sophisticated monitoring equipment [ ] Teaches pregnancy classes [ ] Performs physical examinations on adults and children in remote communities [ ] Delivers babies in remote communities [ ] Performs secretarial work in doctor's offices [ ] Gives immunizations [ ] Delivers nursing care to clients in their homes [ ] Teaches at a university [ ] Educates the public concerning the effects of lifestyle on health [ ] Provides nursing care in private practice [ ] Provides life saving treatment in [ ] emergency situations Counsels employees in industrial centers [ ] Provides screening programs for diabetes, heart disease obesity and stress [ ] Counsels clients in alcohol and drug abuse centers \ 1 53 Acts as consultants for business and community agencies Establishes safety programs in industry Teaches patients about their illnesses Screens children for vision and hearing problems Prepares and manages healthcare budgets Provides health care services within a hospital 24 hours a day Conducts research on various aspects of health care Functions as infection control officers Directs and manages nursing services Serves on hospital ethics committees Counsels mentally ill clients in their homes [ ] 3. What educational preparation do you think a registered nurse has? 4. Would you consider a career in nursing? • Yes • No If yes, please explain why. If no, please explain why not. In you opinion what would have to change (if anything) for the nursing profession to attract more young people? Go immediately to the next page. Please do not turn back to any previous page. 54 O C C U P A T I O N A L I M A G E Your task is to pick out the word that best represents you personal, true feelings about nursing. You will be presented with a series of broken lines with word pairs at either end. Place an X somewhere along the line depending on which word in the pair more closely describes your feelings about the profession. For example one of the lines will look like this. Easy work : : : : : Hard work If you think that a salesperson has an easy job you would place a X at the easy end of the scale. Please make your judgements on the basis of what you think about the categories. There are no correct answers. I want you first impression, your immediate feelings. Please do not worry or puzzle over individual items. Nursing Profession High pay : : : : : Low pay Personally unrewarding : : : : Personally rewarding Low status occupation : : : : : High Status occupation Typically a woman's _ : : : : : Typically a man's occupation occupation Challenging : : : : : Unchallenging Few opportunities for : : : : : Many opportunities for career advancement career advancement Good working hours : : : : : Poor working hours Easy work : : : : : Hard work Chance to supervise self : : : _ _ _ : : No chance to supervise self 55 Occupational Preference In this section please think about your own career choice when making your X's. My chosen career will have/be High pay : : : : : Low pay Personally unrewarding : : : : : Personally rewarding Low status occupation : : : : : High status occupation Typically a woman's : : : : : Typically a man's occupation occupation Challenging : : : : : Unchallenging Few opportunities for : : : : : Many opportunities for career advancement career advancement Good working hours : _ _ _ : : : : Poor working hours Chance to supervise self : : : : : No chance to supervise self Thank you for taking the time to complete this questionnaire. Anna Grieve 

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