Assessment of image of Nursing and Midwifery
Participant accounts and quantitative evaluation suggest the image of nursing and midwifery was both good and bad.
Positive image of nursing and midwifery
Nurses and midwives conduct during care were used as basis for assessing the professional image. A quantitative evaluation of the image of nursing and midwifery showed that respondents rating the image of nursing a five-point Likert scale was positive (M = 21.31, SD = 3.09). Measures assessed included intelligence, importance, independence, respect for profession and self-concept. Results as shown in table 1 revealed that nurses and midwives had a positive image about themselves and the profession. The importance of nursing and midwifery had the highest score M = 4.7, SD = .902).
Table 1 assessment of image
Items
|
M
|
SD
|
It takes intelligence to be a nurse/midwife
|
4.43
|
.911
|
The services given by nurses/midwives is as important as that given by physicians
|
4.65
|
.902
|
Nurses/midwives are capable of independent practice
|
4.29
|
1.01
|
Nursing/midwifery is a respected profession
|
4.04
|
1.10
|
Nurses/midwives feel good about what they do
|
3.90
|
1.02
|
Image score
|
21.31
|
3.09
|
The narrative on the perception of nursing and midwifery suggest a conditional positive outlook.
“…for me, if you look at their work in general, some are good and some are not and depends on the entry point (UER GNE1).
Negative image of Nursing and Midwifery profession
Results in table 1 indicates lower score (M = 3.9, SD = 1.02) for whether nurses and midwives feel good about what they do. This reflects the negative stories about perception of image. Some participants compared events of the past and noted a declining image of the nursing profession in particular. A participant noted the influence of the negative image on the willingness to publicly identify yourself as a nurse or midwife.
“In fact, it is so damaging that wearing uniforms in public is not something that most of us would like to do and even sometimes in places you do not want them to identify that you’re a nurse or a midwife. Because the utterances that you hear you just have to hide back for as much as you can until you leave the place.” (NR RMC)
The negative perception of the image of nursing was observed to be influenced by five factors which were summarised in figure 1 and discussed in subsequent sessions
Determinants of nursing and midwifery image
The key determinants were demographic characteristics, education and training, professionalism, clinical leadership culture and support/regulation of practice as illustrated in figure 1. Demographic factors influencing image of nursing were derived through quantitative analysis while the remaining factors emerged from qualitative outcomes. A parallel approach to reporting was therefore employed.
Demographic factor influencing assessment of the image of nursing and midwifery profession
Education, professional category, rank and duration of practice influenced the image of nursing and midwifery as shown in table 2. Educational background demonstrated statistically significant effect on nursing image, F(3, 772) = 5.10, p =.002). Master’s degree holders rated nursing/midwifery image high, compared with holders of diploma (p = .004). The relationship between how long the participants have work and image of was statistically significant suggesting that individuals who have practiced longer are more likely to have positive image of nursing.
Table 2 Demographic factors influencing image
Variable
|
Descriptive
|
|
|
Inferential
|
|
n
|
M
|
SD
|
F-test values
|
Gender+++
|
|
|
|
.20, ns
|
Male
|
239
|
21.36
|
2.70
|
|
Female
|
539
|
21.32
|
3.17
|
|
Profession Category
|
|
|
|
4.08*
|
Nurse
|
592
|
21.22
|
3.00
|
|
Midwife
|
82
|
21.23
|
2.86
|
|
Nurse-Midwife
|
102
|
22.14
|
3.27
|
|
Education
|
|
|
|
5.10**
|
Diploma
|
175
|
20.80
|
3.02
|
|
Undergraduate
|
370
|
21.25
|
2.98
|
|
Masters
|
221
|
21.83
|
3.09
|
|
PhD
|
10
|
23.10
|
2.02
|
|
Place of Work
|
|
|
|
1.86, ns
|
Training School
|
85
|
21.84
|
3.17
|
|
Teaching hospital
|
155
|
21.15
|
2.70
|
|
GHS Facility
|
312
|
21.43
|
2.83
|
|
CHAG Facility
|
112
|
20.65
|
3.92
|
|
Private hospital
|
39
|
22.21
|
1.79
|
|
Others
|
76
|
21.34
|
1.70
|
|
Place of Training
|
|
|
|
1.96, ns
|
Public University
|
131
|
21.35
|
3.29
|
|
Private University
|
43
|
21.35
|
3.59
|
|
Public NTC
|
557
|
21.24
|
2.96
|
|
Private NTC
|
13
|
21.15
|
2.88
|
|
Quasi-Public
|
38
|
22.66
|
2.27
|
|
Professional Ranks
|
|
|
|
3.07**
|
Staff Nurse
|
70
|
20.16
|
2.98
|
|
Senior Staff
|
105
|
21.29
|
2.59
|
|
Nursing Officer
|
170
|
21.35
|
2.91
|
|
Senior Nursing Officer
|
189
|
21.30
|
2.95
|
|
Principal Nursing Officer
|
98
|
21.96
|
2.65
|
|
DDNS & above
|
84
|
21.90
|
4.12
|
|
Others
|
57
|
21.44
|
2.33
|
|
Professional category exhibited statistically significant effect on nursing image, F(2, 773) = 4.08, p = .017. Post-hoc analysis with Bonferroni procedure revealed that Nurse-Midwife reported significantly better image of nursing/midwifery than Nurses (p = .014) but no difference with midwives (p = .128).
Professional rank exhibited statistically significant effect on image of nursing/midwifery, F(6, 766) = 3.07, P = .002, with staff nurse more likely to report low image of nursing/midwifery than principal nursing officer (p = .002) and individuals with qualifications from DDNS and above (p = .006).
There is no statistically significant relationship between age and image of nursing as reported by the participants. The probable reason could be that the although the age range is from 23 to 64, about 75% were 39 years and below. This age restriction could reduce the variance needed for statistical significance. Gender, place of work and place of training did not significantly influence participants rating of nursing /midwifery image.
Influence of Education and Training on professional image
The nature and quality of educating nurses and midwives was recognised as a factor influencing the professional image. This was manifested through pre-professional motives for choosing nursing and midwifery, increases in student enrolment and competency of tutors.
Pre-professional motives: Intrinsic and extrinsic motivation
The image of nursing and midwifery was perceived to be affected by intrinsic and extrinsic motivation. This was reflected in the dedication and commitment to positively enhance the image of the profession. Additionally, the choice of nursing and midwifery because of easy employment and travel opportunities served as a pull factor that attracted different people into the profession. Some regarded nursing as a gateway to career development while others were coerced by significant others to pursue nursing or midwifery.
Choosing nursing and midwifery because of the passion to care and serve was obvious in the work of those who did nursing out of free will. A participant comparing practice experience said:
“…The work was efficient as compared to now.” “We were more dedicated, more committed and are able to handle the patient very well... (UER_NS2)
However, participants noted choice of nursing and midwifery based on alternative reasons was common. A participant opined that:
“It was easy to get employment so you know, people felt that, instead of going into one profession or the other, they could find themselves in nursing.” (ER GRNMA)
Aside early employment, others indicated that entering into nursing was a conduit for higher achievement and financial gains. The perception of nursing as a job for earning income in some cases is affected quality of care as reflected in the following:
They want to just get a job but do not have the heart. If you don’t have the heart for the job, it means you cannot do it well. (UER GNE1)
Nursing was also seen as the gateway for international travel. The perception that visa acquisition was easier for nurses coupled with shortage of staff in some developed countries fuelled the travelling agenda. A participant commented that:
“I would say that beginning from the early part of 2000, people realized that nursing was the profession that if you decide to enter you could easily travel outside.” (ER GRNMA)
Additionally, coercion from significant others for people to select nursing and midwifery as a career is blamed for the quality of students enrolled.
“It’s a generational thing, because sometimes they will tell you that me, I didn’t like nursing but I was forced into it. So, it is a generational thing starting from the politicians. They are poking their nose so much into the profession” (GAR GHS)
Individual selecting nursing to satisfy parental or political influence turn to have poor work culture and this is perceived to be affecting the image of the nursing and midwifery profession.
Increase in Student enrolment
Participants reported that increase in student enrolment affected the quality of training of nurses and midwives in Ghana. The quality of teaching, class control and supervision of students has been grossly compromised.
“… we are also hit by huge numbers, so what type of quality teaching are you going to do? What supervision are you going to do? So eventually they come out and they cannot perform. You are going to have just a handful who are interested in the job who can do something but the rest cannot. So, you see them, they have nothing to offer…” (UER GNE 1)
The increase numbers were believed to result in lack of attention, poor clinical exposure and inadequate supervision.
Experience of Tutors
Experience of tutors before recruitment to teach in the nursing and midwifery training colleges was considered to affect the training of nurses and midwives. Tutors with more clinical practice were preferred to younger ones who may not have the needed clinical skills. Participants opined that some tutors are ‘half-baked nurses’, immature and unable to train others.
…the tutors are too young, is like the nursing training college is open up too much… if you talk they say you are’collo’ [out of date]. Those days you can’t teach here if you have not practiced for some number of years…the immaturity is too much in the schools… now whether you are a nurse or not you can teach here so everybody comes (NR RME)
The concerns about the competency of trainers of nurses and midwives included the use of avoidance by some tutors to cover up for their inability to give appropriate feedback and support students’ learning. Experienced and competent tutors will train nurses with the right skills and attitudes which will promote positive image of the profession.
Contribution of Professionalism to Perception of image of Nursing and Midwifery
Professionalism of the nurse and midwife in Ghana was described in relation to the physical appearance, competency, attitude and behaviour. According to participants, the image of nurses and midwives in the public eye comes with mixed reactions. The public perception is both positive and negative. However, participant noted a dwindling image attributable to public perception and negative media reports. A participant said:
“…those who know will say that our image is going down. Yes is about 65% and the no is about 35% because when you open the radio and they are talking about Nurses everybody lambast us, everybody keep on saying that we are not up to the task” (WR PHNE)
The physical appearance of Nurses and Midwives
The physical appearance of the nurse or midwife was a quick and easy lens through which participants viewed professionalism. All participant admitted that nurses and midwives are unique professionals who were easily identified by their attire. However, it was reported that most nurses in recent times were either dressed in plain clothes or dressed incompletely. This makes differentiation between a nurse and patient difficult and therefore lowered the confidence and trust that patients had for the nursing and midwifery profession.
“…some of us come to work in the morning dressed anyhow and at times we can’t even differentiate between a nurse and a patient. Very often, the client is in mufti and the nurse is in T-shirt and jeans, so who is attending to who and how do you expect this patient to have that confidence and trust in you?” (AR RHD)
It was also reported that nurses especially are perceived in a more negative professional outlook than midwives. Typically, female nurses were likened to prostitutes because of the way and manner they dressed. Participants mentioned that the younger nurses dressed in short and tight uniforms and use make-ups on their faces as though they were prostitutes. As a result, they do not attract the patients they were to serve.
… some even associate female Nurses to prostitutes, yeah you talk about female Nurses and that is the next word that you hear from the patient, because the dressing alone, you see the dress being short very tight and I wonder whether we are here to work or to showcase our body” (WR NS2)
Similarly, a few participants speculated about the absence of a specific type and style of uniform for nurses makes it difficult for differentiation. Consequently, negative attributes of other individuals assumed to be nurses or midwives affects the image of the profession.
“… the media most of the time are unable to differentiate between Registered Nurses and Health Assistant. ...Probably it was a cleaner or it was a health assistant; that differentiation is not there” (GAR VVU)
The colour of uniform was perceived to affect how the public differentiated qualified nurses from the other professionals Community Health Nurses noted they were perceived as ‘village nurses’ who were not real or qualified.
Behaviour and attitude of the nurse and midwife
According to some participants, some nurses demonstrated caring attitude however, task shifting and use of mobile phones contributed to negative attitude. Task shifting was prevalent among nurses and midwives working during night shifts. Some of them usually sleep resulting in neglect of patients or assigning of roles to patient relatives. In some instances, patients or their relatives had to discontinue infusion and transfusion lines when the nurse were out of reach.
“In fact, the truth of the matter is that during night shifts, most of our activities are given to the patients to do. The relatives see that what we [nurses] do for the patient, they can also do. So, to them, nursing is nothing special” (NR GNC)
The use of mobile phone and social media browsing during working hours was considered inappropriate leading to poor attitude towards care. Some participants noted:
Some nurses especially the young ones are usually on their phones. Sometime when you question them, they will say “my mother has called” (AR RMC 1)
Nevertheless, a few participants acknowledged the positive use of mobile phones and internet during nursing clinical hours.
Clinical competency
Nurses and midwives with expertise and control over their clinical skills were considered to project a good image of the profession. Similarly, challenges associated with translating theory into practice affected professional image. The incompetency resulted in poor attitude towards work. Most of the participants attributed this to lack of mentorship or the lack of resources to support care.
“I think there is a gap between what is learnt and what is practiced, thus, one has to do with practical and then experience actually doing the work practically because when you come out you may have the knowledge but you may not have the practical experience. How to also apply this knowledge becomes a challenge between those in the wards and those who have just come from school” (WR RMN).
Some participants reported that nurses desire for higher academic qualifications without focusing on the skills acquisition. Consequently, the increase in the number of highly qualified professionals is not reflecting on the standard of care.
“… I was thinking that with the universities springing up doing a lot of Degree courses, Mphil, BA [graduate and undergraduate program] we have a whole lot of courses being done but then it is not really impacting on our practice” (WR NS2)
Concerns were raised regarding competency in meticulous documentation. According to a participants, nurses and midwives in Ghana may not be able to redeem their images without proper documentation processes.
Documentation has been a very big problem. I went out with the council here so for supportive supervision in 3 health facilities. It was hell. Documentation is just a problem. How to chart vital signs is a problem and yet a lone to talk about the patograph. (UER NS1)
Influence of Clinical Leadership Culture on professional image
Clinical leadership culture was described with regards to mentorship, monitoring and supervision, resource constraints, educational advancement opportunities and staff
motivation. The adequacy of clinical leadership promoted positive professional image while inadequacy of same projected a negative image.
Mentorship
It was palpable from the data that the young cohorts of nurses/midwives were not ready to learn from the old experienced nurses/midwives or that the old experienced nurses/midwives were not supportive enough to the new and novice nurses and midwives.
“The reason is that the young ones are not ready to be taught. Yes they don’t make themselves available. They have their own agenda” (GAR DNS)
“May be some of us, the old ones, might not have the knowledge, or they are not ready to also share their knowledge with the young ones.” (NR PHNC1)
The results presented evidence that participants especially the older generation of nurses/midwives including patient relatives preferred to be cared for by retired nurses or old nurses instead of the calibre of young generation of nurses. This preference was a consequence of the ill-preparedness in terms of clinical skill and attitude on the part of the young crop of nurses.
“The experienced nurses, some of them are okay, they’re trying to mentor others, and others too are of the view that, well, these young people, they don’t respect, so I’ll not even mind them” (UER RME)
On another breath, it was revealed that among the old experienced nurses are some who were willing to mentor and groom the young nurses only if they showed seriousness to learn.
Monitoring and Supervision
Occasional snap supervisory visits were recognised as a mean of ensuring adherence to standard practice which promote positive professional image. Participants generally argued that clinical leadership culture suggests inadequate supervision and monitoring which has accounted for the low image of nursing and midwifery profession. Commenting of relevance of supervisory visit from Nursing and Midwifery Council, a participant noted that:
“… once in a while I think they [regulatory body] come around but I think they have regional offices so I think they can empower them with that mandate so that even if it once every 6 months, they can go around the schools, they’ll listen to some of the things on the ground ” (UER RME)
Participants’ acknowledged the presence of supervisors but preferred a decentralisation of supervisory roles to regional offices of the Nursing and Midwifery Council. Regular supervision in training schools were also recommended. Another participant reiterating the value of supervision bemoaned the challenges associated with effective supervision.
“We have trained them and we have to supervise them to make sure they are putting up the requisite behaviour. However, this is a major challenge. The supervision is a challenge so we have numerous reasons for this but all is not lost.” (GAR DNS)
Strengthening monitoring and supervision is expected to ensure that nurses and midwives have the requisite qualification and skills to efficiently provide care. Additionally, supervision will enhance appropriate behaviour consistent with professional standards.
Resource Constraints
Resources availability promotes work efficiency while resource constraints affects work output. The poor image of nursing image was attributed to resource constraints. Resources such as personnel and equipment facilitate the quality of care. The absence of basic work tools for nurses and midwives result in frustration, disappointment and loss of hope for nurses and their clients.
“equipment are the main challenge nurses do face …most of the times we have to get a gadget to work with, and then because is not available we have to refer the clients. I think the referral system too is a bit poor ” (WR NS1)
The findings showed that there were times patients were referred to other facilities because of limited resources. And even before the referral, the basic intervention the nurse would have done was not carried out because of resource constraints including lack of beds, oxygen and consumables.
Resource constraints affected timely implementation knowledge and skills acquired as part of continuous education programs. Providing nursing care with limited resources attributed to lack of funds or time directly affects quality of care and indirectly influence how nurses and midwives are perceived by their clients.
Educational Advancement Opportunity
Nursing and midwifery made strides over the years in the introduction of advanced courses of higher learning and opportunities to obtain career development. This was noted among participants as a positive projection of image of the profession.
“…I think right now Nurses we are aiming higher trying to go more into research, trying to develop our own body of knowledge. I think right now Nurses and midwives trying now compared to those times.” (WR NS2)
However, commitment to the work remained problematic among the young generation of nurses/midwives.
“They advance and they learn more things which help the patient management. So, these days the young ones they advance in their knowledge than we the first people. …they have the skills but it’s only that some of them the commitment is not there” (UER NS2)
The findings showed reduced enthusiasm among the old experienced nurses to read books or upgrade themselves with current knowledge in nursing and midwifery.
Motivation to Staff
Motivation to staff reflected as a challenge for nurses/midwives at the work setting. Participants lamented about the demotivating conditions of work. They indicated the type of motivation they needed in order to be happy at work. They desired health insurance cover, fiscal remuneration and fair distribution of accommodation facilities.
“I am getting only my salary there is no motivation, there is no incentive and then when you ask your colleagues who are in different institutions they will say oh Charlie the hospital is trying to give us some coins and we can use it to solve certain problem, and you think about that and you think that oh you are being neglected.” (NR NS2)
Taking part in decision making was one aspect noted to make people motivated. It was evidenced that, intrinsically, nurses feel motivated and committed to the implementation of ideas or strategies that they were part of during the decision-making process.
“… I will be motivated to do something once I get to know that I am part of it in originating the idea …and we have all pledged our commitment, we will not want it to fail.” (UER GNC)
Intrinsic motivation was noticed to be the preferred style of motivating staff by management. Nurses grumbled that management most at time are reproachful to extrinsic motivation when raised at any given opportunity.
Other examples of motivation expressed by nurses included the distribution of uniforms, the institution of extra work hours rewards and the avoidance of delays in promotions when they are due.
Influence of Support and Regulation: Professional Associations and the Regulatory Body
Participants opined that actions and inactions of the regulatory body which is the Nursing and Midwifery Council of Ghana and professional associations such as Ghana Registered Nurses and Midwives Association contributed to the image of the profession. The was a perception of lack of support and weak control of these bodies which accounted for the negative perception held among the participants.
Professional association support
Support from professional associations was considered to be important factor in promoting the image of the nursing and midwifery. However, participants generally were oblivious of the contribution of the Ghana Registered Nurses and Midwives’ Association in the functions of nurses and midwives in Ghana. The association was only known for their monthly financial deductions from members account. It was a general believe that when nurses get into trouble, they are left to their fate. The associations are not seen as fighting for the interest of the individual members.
I don’t see them fighting the nursing course. If they are doing it then they are not meeting our needs. We are told they are for bargaining, that is not the issue I am looking but you have instances where nurses get into serious trouble or have issues and they are left on their own…” (UER GNE2)
Enforcement of rules, regulations and sanctions
The participants identified the professional associations and the Nurses and Midwifery Council as two bodies which can regulate activities of nurses and midwives to redeem the professional image. Participants suggested a host of sanctions and other punitive measures to be enforced.
“…everybody has to be on board nurse managers, the training institutions, the policy makers, the institutions, the clergy both Muslims and Christians and families. We all need to instil values in the students. If they come to the schools the teachers have a part to play” (GAR GHS).
The interview session should be rigorous to actually sieve those who have passion for nursing from those who do not have. Further, careful scrutiny through preliminary examinations should be brought back so that students would justify their inclusion and continuation of the nursing course after one year of their admission.
“…I think it will start from the interview when we are really taking new Nurses at the various institutions that is where we should really make sure that the person love the job. …It is not always about grade, no this person passed very well so we should admit the person, you have to really look at the person’s attitude, the love for the job ” (WR NS2)
Upgrading oneself through workshops and other specialty programmes were noted important to keep abreast with nursing knowledge.
“Nursing really needs reshaping and rebranding. …we can do this by empowering ourselves through workshops, through going for further studies specially with the specialties , GCNM (Ghana College of Nurses and Midwives) has come, GCNM is really trying products from GNCM you can see they are totally different from the post basic now the degree…”,(NR NS1)
It was indicated of the importance of ensuring a credible licensing examination. Participants expressed that the Nursing and Midwifery Council should always maintain examination standards, visit facilities and observe nursing practice. By this, it would improve practice once shortcomings are identified and solutions proffered.
“So council, in order to maintain standards and what not, they should relook at the way their exam is conducted and take charge, financial charge of their exams and also make sure they regularly visit facilities, observe nursing practice, and if there are shortcomings they should be able to provide solutions” (UER GNC)
Examination standards
The examination standards of NMC was reported to have fallen. During examinations, student contribute monies and care for the examiners with gifts and many other things. This was reported to be compromising the examination process because that puts the examiners in tight situations and becomes very difficult to turn and fail students even if they did not perform well.
“What I have observed is that sometimes you have these students, who will have to, sometimes put together some small tokens, as gift. So obviously, … why will you stand before that same person and fail the person? You know, it won’t be fair and I think that is something Council should be looking at” (UER GNC)
The results showed that council should step in and determine the number of students that is admitted since they have a regulatory oversight responsibility. This was believed to contribute to the ‘whole sale’ production of nurses/midwives.
“…though it was not NMC (Nursing and Midwifery Council of Ghana) that admitted them [students] but I think they play a role as a regulatory oversight body, they can determine how many school have the manpower and facilities and insist on the number they can train properly because it is proper training that will determine the kind of nurses we are producing..” (UER GNE2)