PROFESSIONAL
The image of community nursing: implications for future student nurse recruitment Dr Kay M Norman
Senior Lecturer in Nursing, Faculty of Health and Social Care, Open University, Milton Keynes Email: [email protected]
Background Nursing has been reshaped continually over the past century. In its quest to become a respected, worthwhile and desirable career, the profession has continued to strive for an all-encompassing definition and self-understanding (Nelson and Gordon, 2006). The difficulties involved in achieving this are evident, with the traditionally perceived
ABSTRACT
Young people’s perceptions of nursing and, in particular, community nursing, do not reflect the realities of the profession. Community nursing needs to promote a realistic and positive image to young people who may consider nursing as a future career pathway. Strategies to increase awareness and understanding of community nursing roles are urgently required to halt the dissonance between the political drivers influencing changes in community care services, the advancing complexities of nursing roles, and the stereotypical imagery of nursing that continues to influence public thinking and interpretation of roles. The article draws on research that investigated the views of 40 young people from four schools in the West Midlands regarding nursing as a profession.
KEY WORDS
w Community nursing w Nurse’s role w Perception w Recruitment w Schools
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role of the caring doctor’s handmaiden conflicting with the image of the well-educated, autonomous nurse practitioner (Hallam, 2000). Education policy in the UK over the past 20 years has encouraged young people to aspire to higher education and subsequent graduate professions (Gunter et al, 2014). Nursing has arguably been slow to embrace the higher education pathway—completion of an undergraduate degree nursing programme has only been the required educational standard in the profession since 2013 (Buchan and Seccombe, 2010). This delay may have contributed to the continuation of imagery and discourse of nursing as being a vocational pathway with traditional traits and characteristics, rather than an academic discipline requiring professional regulation (Harmer, 2010). The number of nurses and midwives working in the NHS has fallen by almost 6000 in 2 years (Health and Social Care Information Centre, 2012). Furthermore, the profession has not addressed the predicted shortfall in school leavers by planning its recruitment strategies. Therefore, in addition to a retiring workforce and poor retention, it is forecasted that nursing will be in a recruitment crisis by 2020, unless effective strategies are put in place (Buchan and Seccombe, 2010).
Nursing as a career option There are many reasons why young people choose certain career pathways, but it is increasingly apparent that nursing is not being widely considered as a viable option by young people in schools and colleges at present (Neilson and Jones, 2011). Recent media reports on ‘poor standards’ of care and suggestions that nurses lack ‘care and compassion’ seem to have fuelled public unease, challenging traditional beliefs of nursing as a trusted and caring profession (Francis, 2012). This—alongside an increase in educational requirements for nursing programmes that are viewed controversially by some within the profession and the public—has continued to fuel the opinion that the nursing profession is in crisis.
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T
his article will explore the findings from some research investigating young people’s perceptions of nursing. It will discuss the implications of the results of the research for the community nursing profession while illustrating the changing roles in the nursing profession as a whole and political initiatives to provide care closer to home. Opportunities for community nursing to promote a realistic understanding and positive image of the complex roles and responsibilities involved in this area of care delivery are considered.
British Journal of Community Nursing January 2015 Vol 20, No 1
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PROFESSIONAL Research
Sampling methods
It is against this background that a study was conducted to explore the factors that influence young people’s perceptions of both the role of nursing in general, and nursing as a career option, in order to ascertain whether specific elements affect their understanding. The study was not concerned with the construction of factual information and therefore was not intended to be generalisable. The research questions that guided this study are as follows: 1. What perceptions do year 11 pupils have of nursing? 2. In what ways do these perceptions of nursing reflect the discourse(s) within and about the nursing profession, and what role does policy and the media play in this process? 3. Within formal education, what experiences may have influenced their perceptions of nursing as a career? 4. What other factors have impacted on year 11 pupils’ perceptions of nursing?
A convenience sample was considered for this study due to access and resource limitations. Therefore, the sampling process was restricted to schools within the West Midlands area of England. Patton (2002) recognises that convenience sampling is not simply a means to reduce effort, but may be the only way to conduct a study with limited resources of time and people. The issue of access was one that needed to prioritised with regard to sample selection. The sample can also be described as purposive, as the group shared similar characteristics that could be drawn upon to explore identified research questions. Contacts were gathered from local secondary schools within the West Midlands region through colleagues and networks, and by accessing local education authority websites. This resulted in a total of 18 schools being identified, which included 7 out of the 14 local education authorities within the West Midlands regional educational authority.
Methods
A
5
5
Chemistry class consisting of 15 pupils (one of two ‘top’ academic groups)
B
5
5
Mixed (volunteers from year group not attending field trips) approximately 100 pupils
As part of the sampling process, headteachers of these schools were initially emailed to ask for their permission to use the school as part of the study. Details were forwarded explaining the purpose of the study, including an information sheet for parents and pupils, a copy of the interview schedule, and letters for both parents and pupils regarding consent. From those schools contacted, four schools responded with consent for the study to take place. Initial telephone conversations were held with headteachers to discuss and reiterate information-giving strategies, consent processes, digital recording of the interviews, the need for privacy and confidentiality, and the fact that pupils could withdraw from the process at any time. Following discussions with headteachers, academic colleagues and researchers, it was decided that a sample of 40 participants would be appropriate for the study to achieve depth and breadth of data. Each school agreed that 10 pupils could be interviewed (5 males and 5 females). All schools agreed to display information about the study on their school website and noticeboards, to coincide with information being sent out to the identified year groups and classes involved. Volunteers who agreed to be part of the study were asked to contact a specific person within each school. As the headteachers were the ‘gatekeepers’ to the population of this study, the selection of the participants from the group of volunteers was theirs, to ensure minimal disruption to the school day and pupil studies. It was asked for the sample to include pupils from a range of academic abilities, but this could not be verified. Table 1 indicates details of the participant sample.
C
5
5
Health and social care class consisting of 20 pupils
Interview method
D
5
5
Mixed (volunteers chosen by head of year teacher), approximately 120 pupils
The study employed a qualitative interpretive approach drawing on social phenomenology. A qualitative methodology not only incorporates the perceptions of participants, but can also lead to an understanding of the phenomena being explored. Parahoo (2014) suggests that adopting this type of approach is congruent with the philosophy of nursing and highly suitable when studying phenomena relating to nursing and nursing roles. In order to address the research questions posed, the method chosen was individual, face-to-face, in-depth interviews with 40 year 11 pupils (aged 15–16). A semistructured interview schedule was employed, with factual accuracy not being the object of the study, since participants respond to questions and probing within their own versions of reality and social constructs (Alexiadou, 2001).
Ethical approval Ethical approval was gained from the required academic and educational bodies involved.
Table 1. Details of participant sample from each school School
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Male
Female
Sample type
All interviews were conducted on school premises in a quiet room allocated for the purpose of the study. Prior to each individual interview, a description and explanation of the research study was given, with each participant
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Selection procedure
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PROFESSIONAL having the opportunity to ask questions, address any areas of uncertainty, and ensure that they understood their participation was voluntary and they could withdraw from the process at any time. Issues of confidentiality were explained and checked for understanding, including explanation of the procedures for use and storage of recorded material. Written consent was gained. All interviews were recorded using a digital tape recorder and lasted 30–40 minutes. Dates and times were arranged to cause minimal disruption to the participant’s studies over a 6-week period. A brief summary of the main points discussed was given at the end of each interview, which allowed for any clarification of meaning (Morse, 2012).
Data collection All data collected were transcribed verbatim and anonymised. Confidentiality was maintained through the coding of participants and schools (for example, ‘A1M’ would indicate school A, participant 1, male). The data analysis method employed was drawn from approaches advocated by Smith et al (2009), Alexiadou (1999) and Van Manen (1990), as indicated in Box 1. Descriptive comments were made within all transcriptions to record initial thoughts and interpretations. Van Manen (1990) suggests that qualitative analysis should be structured as an ‘organic wholeness’ rather than simply ordering text. However, initial coding was completed, which allowed for conceptual meaning and prompted the formation of categories. At step 4, some overlapping of codes was apparent, and combining categories following further interpretation of data was necessary. Familiar themes were now identified within step 5 and three superordinate themes were identified: w An image of nursing w Nursing as a profession w Social, educational and political influences. A researcher colleague looked at samples of transcripts and interpretations to agree codes and themes.
Results and discussion
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Perceptions of nursing
Participants’ perceptions of nursing overwhelmingly focused on stereotypical images of nurses as caring, kind individuals, working in hospital environments, and being assistants to doctors. Where other professions such as medicine were viewed as highly academic, nurses were seen to ‘only’ care for patients, and seen as being less academic or intellectually able. The individuals’ sense of self-efficacy and expectations of outcomes appeared to contribute to rejections of nursing as a possible career, as individuals’ views of themselves induced them to aspire to something ‘better’ than nursing. Although caring and helping were described as fundamental and positive features of nursing, it continued to be associated with traditional images—particularly as a vocational role with little autonomy or progression opportunities, which concurred with previous studies into the image of nursing (Fletcher, 2007; Stanley, 2008). Knowledge and understanding of the educational
British Journal of Community Nursing January 2015 Vol 20, No 1
requirements, career pathways, and opportunities in nursing were deficient and misguided, and did not reflect the realities of the profession. Nursing was not seen as a profession by many, and appeared to be a choice that would ultimately be discounted if you were a high academic achiever. The social status of nursing was seen as unimpressive compared with other professions such as law, medicine and physiotherapy, and was viewed by some as a last-resort career choice if other options were not realised. These points are illustrated in the following participant quotes:
‘I don’t think you need A levels, do you? I think you train on the job? You wouldn’t need to go to university or anything ... but you might have to go to, like, college or something. I suppose it’s something you do if you’ve always wanted to be a nurse, but it’s not, like, a career ... you can’t go any further with it, apart from being a sister or something. Like in medicine you can work abroad or be a consultant … specialist or GP ... there’s loads of opportunities.’ C7M
Box 1. Step approach to data analysis Step 1 Active listening to individual interview recordings while transcribing data, including note-taking of any relevant pauses, emotions etc. as appropriate. Reading and re-reading the transcripts from recorded interviews to increase familiarisation with the data. Step 2 Within each individual transcript, initial notes on words, sentences, and phrases were highlighted, as suggested by Smith et al (2009), indicating anything of interest. Further familiarisation with the data was achieved through this process by exploring ways in which the participant talked specifically about issues, and their understanding of these issues. These were initially organised as codes, following personal reflection on the interpretations made at that time. Step 3 The initial codes identified were then revisited to allow for conceptual meaning to be revealed. Codes that shared conceptual meaning became categories. This is what Smith et al (2009:89) term ‘the opening up of a range of provisional meanings’. It is this revisiting and engagement with the transcript that sheds new light on initial interpretations. Step 4 The development of emerging themes is the next step within the analysis. Some overlapping of codes between categories was initially identified, which was noted at this point as having a place in a particular category, but also having links to others, as suggested by Alexiadou (2001). Step 5 From the emerging themes now identified within each individual transcript, familiar themes were looked for that were common to all transcripts. This made possible the identification of patterns and theoretical links between themes, which could then be assembled to create a super-ordinate theme as part of a thematic network bringing together the data as a whole. Step 6 Relevant theory underpinning the original research questions was now drawn on in order to understand how the summarised data, with examples from the texts, could form new knowledge and insights, considering alternative positions based on the themes and patterns that had emerged.
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PROFESSIONAL
Nursing was not seen as a viable option to be considered by participants. The reasons for this appeared to be connected with the perception of nursing roles involving cleaning, ‘blood’-related tasks, shift work and poor working conditions. They described nurses as caring, helpful individuals who held certain traits and characteristics and were needed and respected by society, but the images presented did not reflect the discourse, proposed by the Nursing and Midwifery Council (NMC) and Department of Health (DH), of a well-educated, competent, skilled, compassionate individual who leads innovative and evidence-based practice (NMC, 2010; DH, 2012).
Perceptions of community nursing Participants found it difficult to draw on any frame of reference that informed their perceptions of community nursing specifically. They constantly referred to media imagery that portrayed hospital nurses and cited these as reasons not to pursue nursing as career. Although there have been television programmes relating to community nursing (e.g. Frankie, BBC), these were not mentioned by participants in this study. When asked specifically about community nursing and their experience or understanding of this role, many referred to an older family member receiving care at home. However, they did not perceive this to be ‘real’ nursing. This is identified in the following interview extracts:
D1M: ‘Oh yeah, my granddad had someone come in to do his leg when he was bad ... they came every day for ages ... but they’re not proper nurses though, are they? Researcher: ‘What do you mean by a “proper nurse”’? D1M: ‘Well, you know ... the ones that work in the hospital, they do all the proper care, don’t they? ... like, the important stuff.’
‘My nan’s a diabetic and someone came to her house to ask questions to see if she could stay at home and I think they have to give her injections ... She has a dark blue uniform so I know she’s a nurse but it’s not real nursing is it? ... If I think about a nurse, I think about those that work in hospital ... they’re the ones that have to do all the training, don’t they? ... not sure if you have to do as much training if you’re just, like, the ones that go to people’s houses.’ (A10F) These quotes suggest that community nursing has some way to go in promoting its image to young people to give a realistic overview of the role, knowledge and skills needed,
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and the opportunities that community nursing can offer.
Family influences One of the key themes emerging from the study was the impact of family influence on the participants’ perceptions of nursing. It was clear that young people heard and remembered phrases and conversations with parents and family that had influenced their decisions regarding career and educational pathways. For the most part, the young people had followed advice given, or had taken these discussions on board in order to develop their thinking and perceptions. Previous studies have been contradictory in their findings, with some suggesting that family influences play a large part in developing children’s thinking about life choices (Mendez and Crawford, 2002; Miller and Cummings, 2009), while others have suggested that this is only one element of a large range of influencing factors in career choice (White, 2007). Responses from this study suggest that family influence has a major impact on young people’s life choices, particularly with regard to their views on further and higher education, on which careers are better than others, and on expectations concerning likely outcomes of different careers. It is interesting to note that, with regard to nursing, participants whose family members were in the nursing profession all had negative opinions from the conversations they recounted, receiving overwhelming advice against going into nursing, usually along the lines of ‘you can do better’, as seen in the extract below:
‘I definitely wouldn’t go into nursing ... my sister’s a nurse and she used to tell me horrible stories about the patients and that ... she definitely wouldn’t recommend it ... I don’t think she’s ever said she enjoys it ... she’s always saying, “I’d never tell anyone to go into nursing” ... but she does moan a lot ... my mom thinks I can do better with the grades I’ve been getting’. B3F This should be seen as a challenge to the nursing profession, since significant others (not only parents) are seen to play a part in influencing young people’s perceptions of nursing. This concurs with widespread opinion that nurses are themselves disillusioned with the profession and continue to promote a negative image of their career choice (Fletcher, 2007). Although some participants did recall family members or friends who ‘went into people’s homes’ as ‘nurses’, all of these stated that the family member or friend wasn’t happy with the role and was either actively looking for alternative roles in nursing, or had already left the profession. The limited understanding of community nursing roles remained evident, with some participants perceiving the reasons for those family members leaving the profession as ‘not belonging’ to a nursing role within a hospital setting:
‘Well, my auntie was a district nurse, but she left a few years ago ... she went back to college to train to be a midwife ... I think she’s nearly finished now. I think it’s because you need to be a, like, a proper nurse caring for really ill people, don’t you, in a
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‘I think if you need A-levels now and have to get a degree to be a nurse, why would you ever do that? ... I know if you want to be caring, but it’s just cleaning people and talking to them, helping the doctor ... if you were clever enough to go to uni, then you’d do something like medicine or law or something to give you a proper career.’ A2F
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PROFESSIONAL hospital, when you’ve done all that studying? Like, she’ll be back in the hospital when she’s a midwife, won’t she’. C6F ‘One of my mom’s friends did that sort of job—are they called district nurses? She was always moaning, though. I don’t think I’d just like to go round people’s homes all day, it would be really boring and I don’t think you’d be able to use all the training you learned to be a nurse, would you? ... I suppose if you didn’t want to deal with the blood or all the gadgets and that, it might be OK ... or if you were lazy.’ C5F It is important that the positive aspects and experiences of community nursing are promoted and that some pride is taken in the community nursing workforce. The Royal College of Nursing (RCN)-commissioned Willis report (RCN, 2012:45) recommends that ‘the public needs to know what it can expect of registered nurses, and recruitment campaigns should be “scaled up” to promote a better understanding of contemporary nursing’. This is seen to be fundamental in ensuring awareness of the variety of nursing roles and particularly community roles, the educational requirements needed, and potential career opportunities.
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Opportunities to promote community nursing The recent launch of NHS England’s (2014) FiveYear Forward View continues the impetus to deliver care closer to home and to deliver alternative models of care in the community where possible, in order to avoid hospital attendance and admission. The changing role of community nursing to deliver new services brings exciting challenges and opportunities to the profession and should be embraced. Community nursing has the knowledge, skills and leadership capabilities to transform care for patients and to ensure a powerful voice in planning and decision-making strategies for the future of the NHS proposal. In order to do this, community nursing also needs to raise its profile outside of the profession itself and to ensure public awareness of the reality of the complex roles involved in this area of care. In terms of ensuring relevant information and understanding for potential future nurses, community nursing can help to inform young people of the roles and realities of community nursing when considering their future career. It is recommended from this study that the nursing profession liaises with the media in order to increase its awareness of contemporary nursing, establishing an ongoing consultative involvement concerning the representation of nursing in the media. Positive case studies and nursing ‘stories’ need to be shared, and innovative involvement needs to be developed through media sources such as YouTube, phone applications, and social media networks in order to engage with younger groups. Community nursing needs to have an active presence and voice through strategic leadership forums in sharing accounts of this dynamic role. Within the nursing profession, positive role models need to be identified to champion the image of nursing, to inspire,
British Journal of Community Nursing January 2015 Vol 20, No 1
and to encourage conditions that will motivate the current workforce. The culture of the nursing profession needs to be revisited, drawing on nursing history to understand its position, in order to develop strategies to embrace the new roles and responsibilities needed for an ever-changing society. Professional identities within nursing are blurring, with varying interdisciplinary roles becoming apparent that should be embraced rather than argued against (Andrew, 2012). It is evident from this study that parental and family influence is the main factor cited by pupils when considering potential careers. Therefore, it may be useful to establish career advice groups relating to a variety of careers that both pupils and parents could attend. Careers officers could also draw on the nursing profession to ensure an uptodate understanding of the educational requirements, roles and opportunities involved, so that they are in a better position to offer informed advice. Community nurses can be involved at a local level in liaising with schools to offer information on their role, deliver an information session to pupils (this does not necessarily have to take place in a classroom—it could be pre-recorded or in podcast form), or provide written learning materials relating to community nursing experiences. Liaison with local higher education institutions to provide input to marketing materials for pre-registration nursing programmes would help to ensure that community nursing is included and promoted as a central focus for care delivery. Health-care employment and commissioning organisations need to have a strategic recruitment policy aimed at encouraging young people in the age group in this study to consider a career in nursing when career decisions are being formulated. The difficulties in accessing work experience placements for young people still at school need to be addressed. Work experience placements within the community and away from the hospital setting need to be considered, in order to give exposure to the variety of nursing roles available. As implemented within the US (Porter et al, 2009), structured planning of these experiences with identified role models is essential to give a varied exposure to the nursing profession as a whole, with schools and organisations working collaboratively to achieve this.
Limitations of study The types of school that were accessible for this study were classified as ‘major’ urban and ‘other’ urban comprehensive schools. It would therefore be useful to gain perspectives from independent and grammar schools, to compare findings. Furthermore, time for this study was restricted, and it is acknowledged that the sample of volunteers chosen was indicated by the headteachers of schools. The fact that interviews took place within schools may have contributed to participants feeling they needed to respond in a certain way, but this cannot be substantiated. Finally, additional demographics such as participants’ social backgrounds and ethnicity may have enhanced understanding of the responses given. However, access to this information was not possible from the schools involved.
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PROFESSIONAL
Ideas for further research include: w Further explorations of parental and family influences on their children’s career decision-making processes w Examination of how community nursing perceives and portrays itself within the profession and how this affects public perceptions w How community nurses can influence young people’s perceptions of nursing within school settings w Exploring ways that community nurses can influence media portrayals of nursing.
Conclusion The nursing workforce will continue to recruit school leavers who have the required attributes and characteristics and fulfil the mandatory requirements to progress towards a pre-registration nursing programme. However, community nursing was not considered to be ‘real’ nursing by young people in this study. Therefore, community nursing urgently needs to engage with appropriate strategies to promote an awareness and positive image of this area of work.Those who may have alternative perceptions of nursing should consider the reality of community nursing to be a dynamic, complex, deeply satisfying role that can provide a range of opportunities in delivering excellent patient care. BJCN Accepted for publication: 3 December 2014
KEY POINTS w Community nursing needs to promote a positive, realistic representation to young people who may consider nursing as a future career option
w Involvement in political and educational decision-making is essential to raise awareness of the complex roles involved in community nursing
w Champions of community nursing must act as a voice to influence media portrayals of the profession
w Contributions from community nurses in the recruitment processes of potential student nurses will help to promote the image of nursing
Alexiadou N (2001) Researching policy implementation: interview data analysis in institutional contexts. Int J Soc Res Methodol 4(1): 51–69 Andrew N (2012) Professional identity in nursing: are we there yet? Nurs Educ Today 32(8): 846–9. doi: 10.1016/j.nedt.2012.03.014 Buchan J, Seccombe I (2010) Sustaining the Long View: The UK Nursing Labour Market Review 2010. Royal College of Nursing, London. http://tinyurl.com/ q825mat (accessed 3 December 2014) Department of Health (2012) The Mandate: A Mandate from the Government to the NHS Commissioning Board: April 2013–March 2015. Department of Health, London. http://tinyurl.com/mhxbhle (accessed 3 December 2014) Fletcher K (2007) Image: changing how women nurses think about themselves— literature review. J Adv Nurs 58(3): 207–15 Francis R (2012) Independent Inquiry into Care Provided by Mid-Staffordshire NHS Foundation Trust. Stationary Office, London. http://tinyurl.com/o6shv97 (accessed 3 December 2014) Gunter HM, Hall D, Mills C, eds (2014) Education Policy Research. Bloomsbury Press, London Hallam J (2000) Nursing the Image: Media, Culture and Professional Identity. Routledge, London Harmer V (2010) Are nurses blurring their identity by extending or delegating roles? Br J Nurs 19(5): 295–9 Health and Social Care Information Centre (2012) Staff information: nursing workforce. www.hscic.gov.uk/workforce (accessed 10 September 2014) Mendez LM, Crawford KM (2002) Gender-role stereotyping and career aspirations: A comparison of gifted early adolescent boys and girls. Journal of Secondary Gifted Education 8(3): 96–107 Miller K, Cummings G (2009) Gifted and talented students’ career aspirations and influences: a systematic review of the literature. Int J Nurs Educ Scholarsh 6(1): article 8. doi: 10.2202/1548-923X.1667 Morse JM (2012) Qualitative Health Research: Creating a New Discipline. Left Coast Press, Walnut Creek CA Neilson GR, Jones MC (2011) What predicts the selection of nursing as a career choice in 5th and 6th year school students? Nurs Educ Today 32(5): 588–93. doi: 10.1016/j.nedt.2011.06.011 Nelson S, Gordon S (2006) The Complexities of Care. Cornwell University Press, New York NY NHS England (2014) Five Year Forward View. NHS England, London. http://tinyurl.com/p4vo2uz (accessed 3 December 2014) Nursing and Midwifery Council (2010) Standards for Pre-registration Nursing Education. NMC, London. http://tinyurl.com/ojq89gx (accessed 3 December 2014) Parahoo K (2014) Nursing Research: Principles, Processes and Issues. Macmillan, Basingstoke Patton MQ (2002) Qualitative Research and Evaluation Methods, 3rd edn. Sage, London Porter G, Edwards P, Granger B (2009) Stagnant perceptions of nursing among high school students: results of a shadowing intervention study. J Prof Nurs 25(4): 227–33. doi: 10.1016/j.profnurs.2009.01.014 Royal College of Nursing (2012) Quality with Compassion: The Future of Nursing Education. Report of the Willis Commission. Royal College of Nursing, London. http://tinyurl.com/cvugp8t (accessed 3 December 2014) Smith JA, Flowers P, Larking M (2009) Interpretive Phenomenological Analysis. Sage, London Stanley DJ (2008) Celluloid angels: a research study of nurses in feature films 1900–2007. J Adv Nurs 64(1): 84–95. doi: 10.1111/j.1365-2648.2008.04793.x Van Manen M (1990) Researching Lived Experience. State University of New York Press, New York NY White P (2007) Choosing at school: a model of decision-making behaviour within compulsory education. Evaluation and Research in Education 20(1): 32–53
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Recommendations for future research
British Journal of Community Nursing January 2015 Vol 20, No 1
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 27, 2015. For personal use only. No other uses without permission. . All rights re
The image of community nursing: implications for future student nurse recruitment Dr Kay M Norman
Senior Lecturer in Nursing, Faculty of Health and Social Care, Open University, Milton Keynes Email: [email protected]
Background Nursing has been reshaped continually over the past century. In its quest to become a respected, worthwhile and desirable career, the profession has continued to strive for an all-encompassing definition and self-understanding (Nelson and Gordon, 2006). The difficulties involved in achieving this are evident, with the traditionally perceived
ABSTRACT
Young people’s perceptions of nursing and, in particular, community nursing, do not reflect the realities of the profession. Community nursing needs to promote a realistic and positive image to young people who may consider nursing as a future career pathway. Strategies to increase awareness and understanding of community nursing roles are urgently required to halt the dissonance between the political drivers influencing changes in community care services, the advancing complexities of nursing roles, and the stereotypical imagery of nursing that continues to influence public thinking and interpretation of roles. The article draws on research that investigated the views of 40 young people from four schools in the West Midlands regarding nursing as a profession.
KEY WORDS
w Community nursing w Nurse’s role w Perception w Recruitment w Schools
12
role of the caring doctor’s handmaiden conflicting with the image of the well-educated, autonomous nurse practitioner (Hallam, 2000). Education policy in the UK over the past 20 years has encouraged young people to aspire to higher education and subsequent graduate professions (Gunter et al, 2014). Nursing has arguably been slow to embrace the higher education pathway—completion of an undergraduate degree nursing programme has only been the required educational standard in the profession since 2013 (Buchan and Seccombe, 2010). This delay may have contributed to the continuation of imagery and discourse of nursing as being a vocational pathway with traditional traits and characteristics, rather than an academic discipline requiring professional regulation (Harmer, 2010). The number of nurses and midwives working in the NHS has fallen by almost 6000 in 2 years (Health and Social Care Information Centre, 2012). Furthermore, the profession has not addressed the predicted shortfall in school leavers by planning its recruitment strategies. Therefore, in addition to a retiring workforce and poor retention, it is forecasted that nursing will be in a recruitment crisis by 2020, unless effective strategies are put in place (Buchan and Seccombe, 2010).
Nursing as a career option There are many reasons why young people choose certain career pathways, but it is increasingly apparent that nursing is not being widely considered as a viable option by young people in schools and colleges at present (Neilson and Jones, 2011). Recent media reports on ‘poor standards’ of care and suggestions that nurses lack ‘care and compassion’ seem to have fuelled public unease, challenging traditional beliefs of nursing as a trusted and caring profession (Francis, 2012). This—alongside an increase in educational requirements for nursing programmes that are viewed controversially by some within the profession and the public—has continued to fuel the opinion that the nursing profession is in crisis.
© 2015 MA Healthcare Ltd
T
his article will explore the findings from some research investigating young people’s perceptions of nursing. It will discuss the implications of the results of the research for the community nursing profession while illustrating the changing roles in the nursing profession as a whole and political initiatives to provide care closer to home. Opportunities for community nursing to promote a realistic understanding and positive image of the complex roles and responsibilities involved in this area of care delivery are considered.
British Journal of Community Nursing January 2015 Vol 20, No 1
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 27, 2015. For personal use only. No other uses without permission. . All rights re
PROFESSIONAL Research
Sampling methods
It is against this background that a study was conducted to explore the factors that influence young people’s perceptions of both the role of nursing in general, and nursing as a career option, in order to ascertain whether specific elements affect their understanding. The study was not concerned with the construction of factual information and therefore was not intended to be generalisable. The research questions that guided this study are as follows: 1. What perceptions do year 11 pupils have of nursing? 2. In what ways do these perceptions of nursing reflect the discourse(s) within and about the nursing profession, and what role does policy and the media play in this process? 3. Within formal education, what experiences may have influenced their perceptions of nursing as a career? 4. What other factors have impacted on year 11 pupils’ perceptions of nursing?
A convenience sample was considered for this study due to access and resource limitations. Therefore, the sampling process was restricted to schools within the West Midlands area of England. Patton (2002) recognises that convenience sampling is not simply a means to reduce effort, but may be the only way to conduct a study with limited resources of time and people. The issue of access was one that needed to prioritised with regard to sample selection. The sample can also be described as purposive, as the group shared similar characteristics that could be drawn upon to explore identified research questions. Contacts were gathered from local secondary schools within the West Midlands region through colleagues and networks, and by accessing local education authority websites. This resulted in a total of 18 schools being identified, which included 7 out of the 14 local education authorities within the West Midlands regional educational authority.
Methods
A
5
5
Chemistry class consisting of 15 pupils (one of two ‘top’ academic groups)
B
5
5
Mixed (volunteers from year group not attending field trips) approximately 100 pupils
As part of the sampling process, headteachers of these schools were initially emailed to ask for their permission to use the school as part of the study. Details were forwarded explaining the purpose of the study, including an information sheet for parents and pupils, a copy of the interview schedule, and letters for both parents and pupils regarding consent. From those schools contacted, four schools responded with consent for the study to take place. Initial telephone conversations were held with headteachers to discuss and reiterate information-giving strategies, consent processes, digital recording of the interviews, the need for privacy and confidentiality, and the fact that pupils could withdraw from the process at any time. Following discussions with headteachers, academic colleagues and researchers, it was decided that a sample of 40 participants would be appropriate for the study to achieve depth and breadth of data. Each school agreed that 10 pupils could be interviewed (5 males and 5 females). All schools agreed to display information about the study on their school website and noticeboards, to coincide with information being sent out to the identified year groups and classes involved. Volunteers who agreed to be part of the study were asked to contact a specific person within each school. As the headteachers were the ‘gatekeepers’ to the population of this study, the selection of the participants from the group of volunteers was theirs, to ensure minimal disruption to the school day and pupil studies. It was asked for the sample to include pupils from a range of academic abilities, but this could not be verified. Table 1 indicates details of the participant sample.
C
5
5
Health and social care class consisting of 20 pupils
Interview method
D
5
5
Mixed (volunteers chosen by head of year teacher), approximately 120 pupils
The study employed a qualitative interpretive approach drawing on social phenomenology. A qualitative methodology not only incorporates the perceptions of participants, but can also lead to an understanding of the phenomena being explored. Parahoo (2014) suggests that adopting this type of approach is congruent with the philosophy of nursing and highly suitable when studying phenomena relating to nursing and nursing roles. In order to address the research questions posed, the method chosen was individual, face-to-face, in-depth interviews with 40 year 11 pupils (aged 15–16). A semistructured interview schedule was employed, with factual accuracy not being the object of the study, since participants respond to questions and probing within their own versions of reality and social constructs (Alexiadou, 2001).
Ethical approval Ethical approval was gained from the required academic and educational bodies involved.
Table 1. Details of participant sample from each school School
14
Male
Female
Sample type
All interviews were conducted on school premises in a quiet room allocated for the purpose of the study. Prior to each individual interview, a description and explanation of the research study was given, with each participant
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Selection procedure
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PROFESSIONAL having the opportunity to ask questions, address any areas of uncertainty, and ensure that they understood their participation was voluntary and they could withdraw from the process at any time. Issues of confidentiality were explained and checked for understanding, including explanation of the procedures for use and storage of recorded material. Written consent was gained. All interviews were recorded using a digital tape recorder and lasted 30–40 minutes. Dates and times were arranged to cause minimal disruption to the participant’s studies over a 6-week period. A brief summary of the main points discussed was given at the end of each interview, which allowed for any clarification of meaning (Morse, 2012).
Data collection All data collected were transcribed verbatim and anonymised. Confidentiality was maintained through the coding of participants and schools (for example, ‘A1M’ would indicate school A, participant 1, male). The data analysis method employed was drawn from approaches advocated by Smith et al (2009), Alexiadou (1999) and Van Manen (1990), as indicated in Box 1. Descriptive comments were made within all transcriptions to record initial thoughts and interpretations. Van Manen (1990) suggests that qualitative analysis should be structured as an ‘organic wholeness’ rather than simply ordering text. However, initial coding was completed, which allowed for conceptual meaning and prompted the formation of categories. At step 4, some overlapping of codes was apparent, and combining categories following further interpretation of data was necessary. Familiar themes were now identified within step 5 and three superordinate themes were identified: w An image of nursing w Nursing as a profession w Social, educational and political influences. A researcher colleague looked at samples of transcripts and interpretations to agree codes and themes.
Results and discussion
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Perceptions of nursing
Participants’ perceptions of nursing overwhelmingly focused on stereotypical images of nurses as caring, kind individuals, working in hospital environments, and being assistants to doctors. Where other professions such as medicine were viewed as highly academic, nurses were seen to ‘only’ care for patients, and seen as being less academic or intellectually able. The individuals’ sense of self-efficacy and expectations of outcomes appeared to contribute to rejections of nursing as a possible career, as individuals’ views of themselves induced them to aspire to something ‘better’ than nursing. Although caring and helping were described as fundamental and positive features of nursing, it continued to be associated with traditional images—particularly as a vocational role with little autonomy or progression opportunities, which concurred with previous studies into the image of nursing (Fletcher, 2007; Stanley, 2008). Knowledge and understanding of the educational
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requirements, career pathways, and opportunities in nursing were deficient and misguided, and did not reflect the realities of the profession. Nursing was not seen as a profession by many, and appeared to be a choice that would ultimately be discounted if you were a high academic achiever. The social status of nursing was seen as unimpressive compared with other professions such as law, medicine and physiotherapy, and was viewed by some as a last-resort career choice if other options were not realised. These points are illustrated in the following participant quotes:
‘I don’t think you need A levels, do you? I think you train on the job? You wouldn’t need to go to university or anything ... but you might have to go to, like, college or something. I suppose it’s something you do if you’ve always wanted to be a nurse, but it’s not, like, a career ... you can’t go any further with it, apart from being a sister or something. Like in medicine you can work abroad or be a consultant … specialist or GP ... there’s loads of opportunities.’ C7M
Box 1. Step approach to data analysis Step 1 Active listening to individual interview recordings while transcribing data, including note-taking of any relevant pauses, emotions etc. as appropriate. Reading and re-reading the transcripts from recorded interviews to increase familiarisation with the data. Step 2 Within each individual transcript, initial notes on words, sentences, and phrases were highlighted, as suggested by Smith et al (2009), indicating anything of interest. Further familiarisation with the data was achieved through this process by exploring ways in which the participant talked specifically about issues, and their understanding of these issues. These were initially organised as codes, following personal reflection on the interpretations made at that time. Step 3 The initial codes identified were then revisited to allow for conceptual meaning to be revealed. Codes that shared conceptual meaning became categories. This is what Smith et al (2009:89) term ‘the opening up of a range of provisional meanings’. It is this revisiting and engagement with the transcript that sheds new light on initial interpretations. Step 4 The development of emerging themes is the next step within the analysis. Some overlapping of codes between categories was initially identified, which was noted at this point as having a place in a particular category, but also having links to others, as suggested by Alexiadou (2001). Step 5 From the emerging themes now identified within each individual transcript, familiar themes were looked for that were common to all transcripts. This made possible the identification of patterns and theoretical links between themes, which could then be assembled to create a super-ordinate theme as part of a thematic network bringing together the data as a whole. Step 6 Relevant theory underpinning the original research questions was now drawn on in order to understand how the summarised data, with examples from the texts, could form new knowledge and insights, considering alternative positions based on the themes and patterns that had emerged.
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PROFESSIONAL
Nursing was not seen as a viable option to be considered by participants. The reasons for this appeared to be connected with the perception of nursing roles involving cleaning, ‘blood’-related tasks, shift work and poor working conditions. They described nurses as caring, helpful individuals who held certain traits and characteristics and were needed and respected by society, but the images presented did not reflect the discourse, proposed by the Nursing and Midwifery Council (NMC) and Department of Health (DH), of a well-educated, competent, skilled, compassionate individual who leads innovative and evidence-based practice (NMC, 2010; DH, 2012).
Perceptions of community nursing Participants found it difficult to draw on any frame of reference that informed their perceptions of community nursing specifically. They constantly referred to media imagery that portrayed hospital nurses and cited these as reasons not to pursue nursing as career. Although there have been television programmes relating to community nursing (e.g. Frankie, BBC), these were not mentioned by participants in this study. When asked specifically about community nursing and their experience or understanding of this role, many referred to an older family member receiving care at home. However, they did not perceive this to be ‘real’ nursing. This is identified in the following interview extracts:
D1M: ‘Oh yeah, my granddad had someone come in to do his leg when he was bad ... they came every day for ages ... but they’re not proper nurses though, are they? Researcher: ‘What do you mean by a “proper nurse”’? D1M: ‘Well, you know ... the ones that work in the hospital, they do all the proper care, don’t they? ... like, the important stuff.’
‘My nan’s a diabetic and someone came to her house to ask questions to see if she could stay at home and I think they have to give her injections ... She has a dark blue uniform so I know she’s a nurse but it’s not real nursing is it? ... If I think about a nurse, I think about those that work in hospital ... they’re the ones that have to do all the training, don’t they? ... not sure if you have to do as much training if you’re just, like, the ones that go to people’s houses.’ (A10F) These quotes suggest that community nursing has some way to go in promoting its image to young people to give a realistic overview of the role, knowledge and skills needed,
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and the opportunities that community nursing can offer.
Family influences One of the key themes emerging from the study was the impact of family influence on the participants’ perceptions of nursing. It was clear that young people heard and remembered phrases and conversations with parents and family that had influenced their decisions regarding career and educational pathways. For the most part, the young people had followed advice given, or had taken these discussions on board in order to develop their thinking and perceptions. Previous studies have been contradictory in their findings, with some suggesting that family influences play a large part in developing children’s thinking about life choices (Mendez and Crawford, 2002; Miller and Cummings, 2009), while others have suggested that this is only one element of a large range of influencing factors in career choice (White, 2007). Responses from this study suggest that family influence has a major impact on young people’s life choices, particularly with regard to their views on further and higher education, on which careers are better than others, and on expectations concerning likely outcomes of different careers. It is interesting to note that, with regard to nursing, participants whose family members were in the nursing profession all had negative opinions from the conversations they recounted, receiving overwhelming advice against going into nursing, usually along the lines of ‘you can do better’, as seen in the extract below:
‘I definitely wouldn’t go into nursing ... my sister’s a nurse and she used to tell me horrible stories about the patients and that ... she definitely wouldn’t recommend it ... I don’t think she’s ever said she enjoys it ... she’s always saying, “I’d never tell anyone to go into nursing” ... but she does moan a lot ... my mom thinks I can do better with the grades I’ve been getting’. B3F This should be seen as a challenge to the nursing profession, since significant others (not only parents) are seen to play a part in influencing young people’s perceptions of nursing. This concurs with widespread opinion that nurses are themselves disillusioned with the profession and continue to promote a negative image of their career choice (Fletcher, 2007). Although some participants did recall family members or friends who ‘went into people’s homes’ as ‘nurses’, all of these stated that the family member or friend wasn’t happy with the role and was either actively looking for alternative roles in nursing, or had already left the profession. The limited understanding of community nursing roles remained evident, with some participants perceiving the reasons for those family members leaving the profession as ‘not belonging’ to a nursing role within a hospital setting:
‘Well, my auntie was a district nurse, but she left a few years ago ... she went back to college to train to be a midwife ... I think she’s nearly finished now. I think it’s because you need to be a, like, a proper nurse caring for really ill people, don’t you, in a
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‘I think if you need A-levels now and have to get a degree to be a nurse, why would you ever do that? ... I know if you want to be caring, but it’s just cleaning people and talking to them, helping the doctor ... if you were clever enough to go to uni, then you’d do something like medicine or law or something to give you a proper career.’ A2F
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PROFESSIONAL hospital, when you’ve done all that studying? Like, she’ll be back in the hospital when she’s a midwife, won’t she’. C6F ‘One of my mom’s friends did that sort of job—are they called district nurses? She was always moaning, though. I don’t think I’d just like to go round people’s homes all day, it would be really boring and I don’t think you’d be able to use all the training you learned to be a nurse, would you? ... I suppose if you didn’t want to deal with the blood or all the gadgets and that, it might be OK ... or if you were lazy.’ C5F It is important that the positive aspects and experiences of community nursing are promoted and that some pride is taken in the community nursing workforce. The Royal College of Nursing (RCN)-commissioned Willis report (RCN, 2012:45) recommends that ‘the public needs to know what it can expect of registered nurses, and recruitment campaigns should be “scaled up” to promote a better understanding of contemporary nursing’. This is seen to be fundamental in ensuring awareness of the variety of nursing roles and particularly community roles, the educational requirements needed, and potential career opportunities.
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Opportunities to promote community nursing The recent launch of NHS England’s (2014) FiveYear Forward View continues the impetus to deliver care closer to home and to deliver alternative models of care in the community where possible, in order to avoid hospital attendance and admission. The changing role of community nursing to deliver new services brings exciting challenges and opportunities to the profession and should be embraced. Community nursing has the knowledge, skills and leadership capabilities to transform care for patients and to ensure a powerful voice in planning and decision-making strategies for the future of the NHS proposal. In order to do this, community nursing also needs to raise its profile outside of the profession itself and to ensure public awareness of the reality of the complex roles involved in this area of care. In terms of ensuring relevant information and understanding for potential future nurses, community nursing can help to inform young people of the roles and realities of community nursing when considering their future career. It is recommended from this study that the nursing profession liaises with the media in order to increase its awareness of contemporary nursing, establishing an ongoing consultative involvement concerning the representation of nursing in the media. Positive case studies and nursing ‘stories’ need to be shared, and innovative involvement needs to be developed through media sources such as YouTube, phone applications, and social media networks in order to engage with younger groups. Community nursing needs to have an active presence and voice through strategic leadership forums in sharing accounts of this dynamic role. Within the nursing profession, positive role models need to be identified to champion the image of nursing, to inspire,
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and to encourage conditions that will motivate the current workforce. The culture of the nursing profession needs to be revisited, drawing on nursing history to understand its position, in order to develop strategies to embrace the new roles and responsibilities needed for an ever-changing society. Professional identities within nursing are blurring, with varying interdisciplinary roles becoming apparent that should be embraced rather than argued against (Andrew, 2012). It is evident from this study that parental and family influence is the main factor cited by pupils when considering potential careers. Therefore, it may be useful to establish career advice groups relating to a variety of careers that both pupils and parents could attend. Careers officers could also draw on the nursing profession to ensure an uptodate understanding of the educational requirements, roles and opportunities involved, so that they are in a better position to offer informed advice. Community nurses can be involved at a local level in liaising with schools to offer information on their role, deliver an information session to pupils (this does not necessarily have to take place in a classroom—it could be pre-recorded or in podcast form), or provide written learning materials relating to community nursing experiences. Liaison with local higher education institutions to provide input to marketing materials for pre-registration nursing programmes would help to ensure that community nursing is included and promoted as a central focus for care delivery. Health-care employment and commissioning organisations need to have a strategic recruitment policy aimed at encouraging young people in the age group in this study to consider a career in nursing when career decisions are being formulated. The difficulties in accessing work experience placements for young people still at school need to be addressed. Work experience placements within the community and away from the hospital setting need to be considered, in order to give exposure to the variety of nursing roles available. As implemented within the US (Porter et al, 2009), structured planning of these experiences with identified role models is essential to give a varied exposure to the nursing profession as a whole, with schools and organisations working collaboratively to achieve this.
Limitations of study The types of school that were accessible for this study were classified as ‘major’ urban and ‘other’ urban comprehensive schools. It would therefore be useful to gain perspectives from independent and grammar schools, to compare findings. Furthermore, time for this study was restricted, and it is acknowledged that the sample of volunteers chosen was indicated by the headteachers of schools. The fact that interviews took place within schools may have contributed to participants feeling they needed to respond in a certain way, but this cannot be substantiated. Finally, additional demographics such as participants’ social backgrounds and ethnicity may have enhanced understanding of the responses given. However, access to this information was not possible from the schools involved.
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PROFESSIONAL
Ideas for further research include: w Further explorations of parental and family influences on their children’s career decision-making processes w Examination of how community nursing perceives and portrays itself within the profession and how this affects public perceptions w How community nurses can influence young people’s perceptions of nursing within school settings w Exploring ways that community nurses can influence media portrayals of nursing.
Conclusion The nursing workforce will continue to recruit school leavers who have the required attributes and characteristics and fulfil the mandatory requirements to progress towards a pre-registration nursing programme. However, community nursing was not considered to be ‘real’ nursing by young people in this study. Therefore, community nursing urgently needs to engage with appropriate strategies to promote an awareness and positive image of this area of work.Those who may have alternative perceptions of nursing should consider the reality of community nursing to be a dynamic, complex, deeply satisfying role that can provide a range of opportunities in delivering excellent patient care. BJCN Accepted for publication: 3 December 2014
KEY POINTS w Community nursing needs to promote a positive, realistic representation to young people who may consider nursing as a future career option
w Involvement in political and educational decision-making is essential to raise awareness of the complex roles involved in community nursing
w Champions of community nursing must act as a voice to influence media portrayals of the profession
w Contributions from community nurses in the recruitment processes of potential student nurses will help to promote the image of nursing
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Recommendations for future research
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